Coordinates and implements the Quality Management/Performance Improvement Program at the facility.

Conducts education on quality management and performance improvement theoretical frameworks to promote high quality patient care. Assists in developing appropriate measurements to assess processes and outcome of patient care. Reviews and evaluates the Performance Improvement Program and the Organizational Performance Improvement/Safety Plan annually. Recommends organizational objectives and implements related strategic plans.  Fosters participation in all Performance Improvement initiatives to share and learn best practices.

Implements organizational Performance Improvement methodologies and promotes effective patient safety to improve processes and patient care outcomes. 

Assists in identifying and prioritizing opportunities for improvement and recommends selected studies/focused reviews to evaluate and improve quality of patient outcomes. Promotes failure mode effects analysis (FMEA) as a methodology for proactive assessment to improve care delivery. Evaluates quality indicator data for internal comparative analysis and externally on all hospital priority areas including Centers for Medicare and Medicaid Services (CMS), American Hospital Association (AHA), core measures, Institute for Healthcare Improvement (IHI), and patient safety indicators. Assists in the systematic measurement, evaluation, and reevaluation of performance when interventions take place. Facilitates the use of outcome measurement data to improve departments/ services related to internal data including mortality, readmissions, morbidity, serious events and near misses Reviews data related to patient satisfaction, patient complaints, positive comments, as well as, any other organizational service excellence related data to develop best practice models and care processes.

Ensures institutional compliance with governmental/regulatory rules and      regulations and oversees state reportable patient occurrences.           

Collaborates with organization leaders to develop policies, procedures, guidelines, or protocols that ensure compliance with regulatory and accreditation requirements. Interprets and distributes information about healthcare statutes, regulations, and standards as they are published by the regulatory and/or accreditation agencies. Oversees DOH survey activity related to patient complaints and coordinates responses to Statements of Deficiency. Oversees incident reporting to the DOH in accordance with regulatory requirements.  Ensures follow-up of plan-of-correction with appropriate tracking, measuring, and reporting.  Sets-up and facilitates case review meetings; provides support (sentinel event/root cause analysis). 

Communicates quality initiatives and establishes processes for constant survey readiness. 

Identifies areas of vulnerability in conjunction with medical and nursing leadership and other appropriate professionals.  Facilitates the development of strategies to enhance compliance and minimize resource expenditure.  Assists with the evaluation of standard compliance for Periodic Performance Review and makes recommendations on measures of success. Acts as liaison to corporate quality for dissemination of information.

Performs related duties, as required.

 

*ADA Essential Functions

Experience and Qualifications:

Bachelor’s Degree in Nursing, required.  Master’s Degree, preferred. Current license to practice as a Registered Professional Nurse in New York State. Certified Professional in Healthcare Quality (CPHQ), preferred. Working knowledge of facilitation, sentinel event/root cause analysis, and/or failure mode effects analysis (FMEA) skills. 3 years of post-operative surgical nursing required, 5 years preferred.

Excellent interpersonal, presentation and communication skills.