Director of of Quality and Regulatory

• Coordinate NYSDOH/CMS & TJC data collection and submission per policy and procedure.

• Development of policies and procedures that adhere to best practices/evidenced-based practices within the context of regulatory guidance.

• Responsible to maintain all NYSDOH, Primary Center’s Stroke Team’s education requirements annually.

• Responsible for performance improvement. P&P. physician relations, program development, education and community outreach strategies.

• Assist in overseeing the duties/functions necessary to assure regulatory and accreditation compliance and advising the vice president, hospital staff on these issues.

• Assist in coordination of regulatory survey and reporting activities within the organization which would include staff compliance with patient safety goals and compliance with TJC, NYSDOH, CMS and other regulatory standards.

• Collaborate with cross-functional teams to deliver enterprise quality solutions.

• Daily, weekly or monthly monitoring of the QA process to ensure that the methods are being followed. Constant reinvestment in regression testing procedures, test plans and staff education.

• Maintain a level of knowledge on the internal systems in order to provide support to QA staff.

• Define and implement testing methodology that incorporates best practices for new systems and current system enhancements.

• Responsible for the development of QA metrics and targets for processes and initiatives to assure all manual and electronic (EHR) documentation formats work independently and together in a high quality manner.

• Address all QA and be highly visible as the champion of QA to both internal and external clients.

• Develop and monitor unit/department specific QA/PI plans, initiating appropriate action to improve outcomes.

• Monitor and assist in development of initiatives/measures to mitigate patient safety indicators (PSIs) and hospital acquired conditions (HACs).

• This position has cross interactions with Risk Management, Graduate Medical Education HIM/Coding, and any other applicable areas, in support of improving overall patient care.

• Coach, mentor and lead highly dynamic team members to help achieve the requirements of this position as well as the individual career goals of team membersDirect National Hospital In-patient and Out-patient Quality Reporting Program (Core Measures); Maintain associated dashboards.

• Chair the Core Measure Team Meetings for reviewing of dashboards, outcomes, and corrective actions required for performance improvement, patient safety and staff education.

• Coordinate evidenced based medicine and performance improvement activities of the clinical staff. These activities include Core Measures and other internal and external quality initiatives that are underway or required

• Responsible as liaison between hospital and NYSDOH

• Participate in and/or coordinate the functions of the various hospital wide quality committees. Serve as consultant to the Medical Staff Committees and Department Managers as needed.

• Work collaboratively with physicians, nurses and case managers and other health care disciplines utilizing a team approach when applicable.

• Act as clinical consultant regarding excellence in clinical care for the Sepsis patient population. Work in collaboration with the Stroke Coordinator- regarding data collection & analysis that may impact outcomes and continuous performance improvement. Ensure continuity between clinical practice and standards of care to patients with sepsis.

Formal Education and Job-RelatedExperience This position requires a minimum formal education of Bachelor's Degree and a minimum of 3-5 years

job-related experience.RN License preferred but not necessary previous experience in quality /regulatory required

Shift - Monday through Friday 9am-5pmSalary - 145-165 K