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Director, Quality Management (Rn)

Expired Job

Northwell Health Bay Shore , NY 11706

Posted 5 months ago

Job Description:

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.

Responsibilities Include:
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.

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Director, Quality Management (Rn)

Expired Job

Northwell Health