Req Number 138875

Job Description

Manages and develops a multidisciplinary performance improvement program focusing on regulatory preparation, policy/procedure standardization, measurements, and performance improvement initiatives/activities within hospital.

Job Responsibility

Provides leadership to Quality Management Performance Improvement team members, supervisors, and managers by communicating and guiding toward achieving department objectives.

Develops, communicates, and builds consensus for goals in alignment with the health system.

Monitors and maintains institutional compliance with governmental/regulatory rules and regulations; coordinates plans of correction for Statement of Deficiencies; forms and staffs committees to assess and ensure compliance with plans for corrective action; oversees survey activity related to patient complaints and coordinates responses to all Statements of Deficiency.

Coordinates all incidents reporting to the Department of Health in accordance with regulatory requirements; coordinates all reporting as required under the Safety Medical Device Act; acts as a resource person and educate hospital personnel regarding risk management related medical, legal and regulatory issues; participates in various committees of the organization.

Serves as a survey coordinator to the New York State Department of Health and other governmental and regulatory agencies during on-site inspections and surveys; participates in and/or coordinates root cause analysis as required under the; develops the health systems and procedures to carry out quality management/performance improvement functions; participates in Department/Service PI Hospital committees, task forces, and organizational performance improvement teams as appropriate.

Recommends selected focus studies to evaluate and improve quality patient care; keeps abreast of new and revised regulatory agency requirements; collaborates with the multidisciplinary health care team regarding development and implementation of the quality management program; serves as a consultant to the multidisciplinary Department/Service performance improvement committee.

Participates in the Hospital employee orientation in the absence of the leadership; recommends topics for review, including (but not limited to) high risk, high volume or problem-prone activities, facilitating the performance improvement framework for all projects; provides education to the multidisciplinary Department/Service to accomplish the goals and techniques of performance improvement; collaborates with health care professionals within the hospital to identify areas for prioritization and ensure optimal appropriateness and quality of patient services are rendered.

Assists in the preparation process for accreditation and regulatory surveys; demonstrates familiarity with standards of accreditation and regulatory agencies; assists with assessment of adherence to these standards; makes judgments regarding incident reporting as appropriate to State and Federal agencies required by laws, regulation or other licensing bodies; monitors and evaluates results of surveys as it related to performance improvement opportunities.

Monitors Hospital compliance with external regulatory agencies; supports an information the health system for the data aggregation for Risk/Quality Management; timely collection and maintenance of information from different sources, including (but not limited to) past claims, incident reports, and patient complaints.

Ensures the integration of quality management activities with risk management and ongoing evaluation, including monitoring of appropriate corrective actions/improvements to ensure resolution; manages and supports risk management database; reviews and screens all occurrence reports.

Maintains and supports the database; tabulates, analyzes, and trends data; reports significant findings as necessary.

Performs related duties as required. All responsibilities noted here are considered essential functions of the job under the Americans with Disabilities Act. Duties not mentioned here, but considered related are not essential functions.

Job Qualification

BSN nursing degree, required. Current License to practice as a Registered Professional Nurse in New York State required, plus specialized certifications as needed.

6+ years of relevant experience, 5+ years of leadership/management experience, required.

*Additional Salary Detail

The salary range and/or hourly rate listed is a good faith determination of potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement and may be modified in the future.When determining a team member's base salary and/or rate, several factors may be considered as applicable (e.g., location, specialty, service line, years of relevant experience, education, credentials, negotiated contracts, budget and internal equity).

The salary range for this position is $114,000-$182,000/year

It is Northwell Health’s policy to provide equal employment opportunity and treat all applicants and employees equally regardless of their age, race, creed/religion, color, national origin, immigration status or citizenship status, sexual orientation, military or veteran status, sex/gender, gender identity, gender expression, disability, pregnancy, genetic information or genetic predisposition or carrier status, marital or familial status, partnership status, victim of domestic violence, sexual or other reproductive health decisions, or other characteristics protected by applicable law.