Plans, organizes and directs the staff and activities of the Quality Management/ Performance Improvement Program to achieve approved clinical goals and strategic operating plans and objectives. Ensures compliance with regulatory agencies in accordance with internal and external requirements/regulations. Promotes effective patient safety and performance improvement initiatives to improve processes and outcomes of patient care.
1.Plans and directs all aspects of the Quality Management/Performance Improvement Program at facility.
Develops methodologies that enhance problem-solving and effective resolution of identified patient care issues.
Oversees orientation and education on quality improvement and performance improvement theoretical frameworks that promote high quality patient care.
Develops and implements appropriate measurements to assess processes and outcome of patient care.
Facilitates a multidisciplinary approach to issue resolution and process improvement.
Reviews and evaluates the Performance Improvement Program and the Organizational Performance Improvement/Safety Plan annually.
Fosters participation in all NS-LIJHS Performance Improvement initiatives to share and learn best practices.
Develops Performance Improvement Coordinating Group (PICG) agenda (with Chairman and Vice-Chairman PICG) to ensure all relevant reporting including performance improvement prioritization. Produces PICG minutes for distribution to members, Administration and Medical Board.
Maintains and ensures confidentiality of all Quality Assurance documents in accordance with statutory regulations.
2.Ensures compliance with regulatory requirements with regard to statutory standards.
Provides ongoing regulatory updates on quality management/performance improvements to the PICG.
Prepares presentation of monthly reports to Joint Conference/Professional Affairs Committees.
Oversees investigation and reporting as required with DOH NYPORTS Program and Sentinel Event reporting with submission of root cause analysis findings and recommendations.
Maintains current knowledge of regulatory changes pertaining to Quality Assurance/Performance Improvement activities.
Coordinates and communicates all on-site surveys pertaining to Quality Assurance/Performance Improvement activities.
3.Promotes effective patient safety and performance improvement initiatives to improve processes and outcomes of care.
Facilitates performance of Root Cause Analysis with Clinical and support services to effect improvement in processes of care delivery.
Promotes failure mode analysis as a methodology for proactive assessment to improve care delivery.
Collaborates with all departments/services on performance improvement initiatives.
Participates in prioritization of performance improvement teams.
4.Collaborates with System Quality Management.
Prepares and oversees the hospital's monthly reports to the JC/PA Acute Care/Behavioral Health, Ambulatory Care Committees.
Attends the monthly QM Directors/System PICG, JC/PAC meetings.
Ensures system Quality Management is notified of all serious patient safety/adverse occurrences including potential sentinel events.
Shares best practices and lessons learned with members of NS-LIJHS.
5.Develops and manages direct reports and oversees the development and management of their staff.
6.Demonstrates ability to manage department in a fiscally responsible manner.
Uses labor and non-labor resources in an appropriate and cost efficient manner.
Develops and manages the department budget within approved guidelines.
Recommends and implements approved cost saving ideas using the most economical path.
7.Performs related duties as required.
Master's Degree in Nursing, Health Services, Allied Health or related field, required.
Current license to practice as a Registered Professional Nurse in New York State.
Minimum of seven (7) years administrative experience in Quality Management Utilization Management.