POSITION SUMMARY:

Provides leadership and support for the clinical operations and patient care coordination of the Stroke Center and neurology programs. Responsible for the development and implementation of the processes that facilitate patient care, care coordination, quality of care and achieve desired programmatic goals in collaboration with physicians and hospital leadership. Works with leadership team to establish, implement and monitor programs. Also directly works with patients to assist them in adhering to their plan of care and promote delivery of excellent service and high quality clinical outcomes. Responsible for growth of programs and achievement of financial targets set for programs.

POSITION EDUCATION/QUALIFICATIONS:

• Bachelor’s Degree in Nursing preferred.
• Current RN licensure by Texas State Board of Nurse Examiners

JOB KNOWLEDGE/EXPERIENCE:

• 2-3 years experience in critical care/neuro preferred
• Knowledge in data collection, analysis, and input required
• Excellent organizational skills
• Understands concepts of performance improvement and research and is able to coordinate performance improvement initiatives and projects.
• Background in cerebrovascular disease/stroke care or prior experience with processes and workflows in an inpatient setting is strongly desired. Experience with The Joint Commission Primary and/or Comprehensive Stroke Center certification (Disease Specific Care Certification). Experience with Stroke Core Measures and/or Stroke Get with the Guidelines abstraction and reporting. Experience in clinical process improvement Experience in clinical quality, safety and management work Lean or Six Sigma methodology experience
• Ability to simultaneously oversee multiple projects
• Excellent customer service skills.
• Computer skills required with knowledge of Microsoft Office suite.
• Good written and verbal communication skills required.
• Bilingual preferred – English/Spanish

POSITION RESPONSIBILITES

• Promotes the facility mission, vision and values by effectively communicating them to others. Considers mission, vision and values in developing services, standards and practices.
• Assists with the management and development of the quality metric monitoring required to achieve and maintain certification which includes, but is not limited to all data elements for certification by The Joint Commission such as data elements for (1) compliance monitoring for The Joint Commission (TJC) Comprehensive Stroke Center Primary and CSC core measures and requirements, (2) Centers for Medicare and Medicaid Services (CMS) quality reporting requirements metrics (3) American Heart Association Get With the Guidelines Quality Measures (AHA-GWTG) and (4) internal quality improvement data for initiatives such as Stroke Arrival Process metrics as well as patient satisfaction, clinical outcomes, safety, efficiency metrics, activity data and other data as requested.
• Helps facilitate process improvement, coordinate improvement plans for the stroke program and guide diverse groups to reach consensus regarding appropriate interventions.
• Will abstract, merge, manage, and prepare compliance and quality data in the form of useful information to aid analysis by CSC Leadership (Chairs, Directors, and Manager) who, with this information, can enhance the quality of clinical care for the stroke patients.
• Chart Abstraction /Audits: Develops and maintains tracking method for concurrent review of stroke patients to ensure compliance with all quality metrics. Performs accurate and timely data abstraction including but not limited to data for CMS, TJC, GWTG, QA initiatives, and the internal Stroke Log. Review all IV tPA and endovascular intervention cases to ensure protocols were followed; research details when problems arise, present case to Leadership. Maintains knowledge of measure specifications and data definitions necessary to complete this work. Participates in or leads inter-rater reliability sessions to ensure abstraction accuracy and success in external agency validation. Provides training to other team members and serves as a resource for data abstraction requirements, ensuring reliability and validity of data.
• Data Management:Works with data from many different clinical and administrative sources (internal and external) and has expertise to abstract, merge, manage, and prepare the data in the form of useful information to aid in analysis. Creation and maintenance of program specific patient satisfaction data as requirement by TJC, assessing and communicating trends for CSC leadership to determine correct interventions to reduce readmission rates and manage patient needs in correct level of care setting
• Data Review and Quality Improvement Support:Thoroughly reviews clinical metric performance, assess for trends and underlying causes for deficiencies for escalation and review by the CSC Program Manager. Participates in a CSC quality review meetings to support the data analytic portion of the process. Attends morbidity and mortality conferences for neurology, neurosurgery, neurointerventional radiology, and vascular surgery to ensure compliance with the monitoring and review of complication and mortality data as required for CSC programs. Monitor changes in laws, regulations and policies (specifically in the federal registrar that impact performance measurement and reimbursement) and assure compliance with reporting procedures and work flows.
• Reporting:Expertly produces all internal and external performance reports which include but are not limited to Stroke Core Measures, Stroke GWTG, Stroke Arrival, M&M Review, Comprehensive Stroke Measures, and CSC program specific elements that assist the CSC leadership in managing quality patient care to stroke patients as well as the program overall. Creation and maintenance of a real time dashboard for clinicians to utilize in increasing performance of our quality metrics for delivering interventions (IV tPA and endovascular therapies) to stroke patients. Provides reports for ad hoc meetings to address specific areas of deficiency. Maintains all databases for the CSC program and responds to requests by providers for data for research purposes. Provides training for report creation and serves as a resource for other team members, ensuring reports meet the standards of timely, discernible, reliable, meaningful, and actionable.
• On-Site Review: In collaboration with the CSC Program Manager, provide guidance and assistance in preparation for on-site surveys for TJC, as well as follow-up for areas of performance requiring attention identified during the survey. Aids the CSC Program Manager in the creation and distribution of tools and educational materials to improve understanding of and meet TJC requirements and expectations. Is available onsite, in the 7 business days prior to, and during the TJC survey.
• Education: Provide education references to clinicians (physicians, nurses, APN/PA, etc.) related to clinical metric performance requirements within CSC.
• Process Improvement/Joint Commission Compliance: In collaboration with the CSC directors, program manager, and other CSC team members, identifies areas of opportunities and conducts team meetings; recommend and evaluate processes to improve systems and patient care across the continuum of care; responsible for coordinating the efforts with team members for the development of performance improvement and action plans. Serves as subject matter expert for stroke center certification in response to inquiries from other departments such as emergency medicine, neurology, neurosurgery, vascular surgery, neurointerventional radiology, PT, OT, SLP, nursing units, etc.
• Provides support to CSC physician directors and program manager in design and delivery of care management of stroke patients: With physician leadership and program manager: Review and monitor care for the stroke population; review and revise provider ordersets, treatment guidelines, etc. and ensure alignment between the various protocols and ordersets that impact stroke patient care; reviews and maintains policies and procedures specific to the CSC.
• May coordinate education, communication, process improvement, and case reviews with prehospital providers.
• Participates in, coordinates and convenes CSC Standing & Ad Hoc Meetings: Chair or co-chair committees as assigned. Create agendas, produce meeting minutes, assign action items, and follow-up on tasks assigned.
• Assists with utilization, community outreach, patient advocacy, staff and physician education and marketing communications.

• Develop a comprehensive work plan for implementation of the project elements (new and ongoing activities).
• Monitor quality utilization, financial outcome indicators, and monitors implementation of data to achieve established targets.
• Effectively uses data in decision-making
• Actively participate on assigned committees.
• Assists in the research and development of new patient care protocols and provides staff support for research activities.
• Completes special assignments as assigned.
• In addition to the essential job elements and duties listed here, other duties may be assigned or assumed which are within the scope of the employee’s skill, expertise and licensure or certification.
• Other duties as assigned.

LINES OF RESPONSIBILITY:

Vice President of Neurosciences; Chief Nursing Officer