Overview

Assists VP of QA/PI in managing, planning, coordinating and directing the System’s/Hospital’s Quality Control Program, which is designed to ensure and enhance continuous quality of care and foster excellent patient outcomes consistent with established standards and regulations.

Responsibilities

• Identify care processes with the greatest variation and the largest improvement opportunity.
• Ensures appropriate and timely escalation of quality issues, including potential misconduct or issues of significant deviation with regulatory standards to the Chief Quality Officer, SVP, VP or/and Chair of Department.
• Conducts chart review for NYPORTS events and actual/potential quality of care issues.
• Coordinates written responses to TJC, CMS, IPRO, NHSN or other regulatory Agencies regarding Care Concerns and citations.
• Monitor and facilitate closure to all quality-related issues communicated by NYS DOH, The Joint Commission, CMS and other external regulators
• Centralizes and tracks/trends the hospital mortality review process and returns to the operating room.
• Research and recommend implementation of "evidence-based" performance measures
• Performs CMS data abstraction in the specified timeframes.
• Assists in the maintenance of physician quality management files.
• Conducts/performs special studies/audits as needed and communicates results to relevant stakeholders, to ensure corrective and preventive actions are taken.
• Interfaces and provides day-to-day support, training and mentorship to QA staff to ensure appropriate quality oversight
• Assist with the preparation of quarterly reports of the status and outcomes of the Performance Improvement Program for the Board of Trustees.
• Conduct annual Performance Improvement Program Assessment to identify opportunities for streamlining and improving processes
• Assists the VP of Quality with other activities as needed.
• Performs other duties as required.

Qualifications

Position Requirements:

• BA/BS with a preference for a graduate degree in a major healthcare-related field.
• NYS RN Licensure
• At least three to five years in clinical quality management and performance improvement in a hospital with a successful track record.
• Advanced knowledge of PI principles and extensive experience in facilitating improvement initiatives.
• Knowledge of CMS, TJC and other applicable regulations
• Have already built and run a Performance Improvement Operation.

Language Skills:

• Excellent verbal/written/communication skills and a hands-on leader.
• Familiar with the operations of Hospital departments.

Skills:

• Strong people skills.
• Political savvy, energy, poise and resourcefulness are essential for success.
• Computer knowledge and skills.
• Excellent creative writing skills

Physical Demands:

• Involves standing, walking, sitting, talking, hearing and bending.
• May include some repetitive motions.
• Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the position without compromising patient care.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions without compromising patient care.

The statements herein are intended to describe the general nature and level of work being performed by employees, and are not to be construed as an exhaustive list of responsibilities, duties, and skills required of personnel so classified. Furthermore, they do not establish a contract for employment and are subject to change at the discretion of One Brooklyn Health System (OBHS), and Interfaith Medical Center (IMC).

One Brooklyn Health System (OBHS), and Interfaith Medical Center are an equal opportunity employer, it is our policy to provide equal opportunity to all employees and applicants for employment without regard to race, color, religion, national origin, marital status, military status, age, gender, sexual orientation, disability or handicap or other characteristics protected by applicable federal, state, or local laws.