Specialist, Quality Management (RN) \/ Full Time Day Shift \/ Experience with care or management of post-operative\/surgical patients, or neurology\/neurosurgery required

Employment Type

: Full-Time


: Healthcare - Nursing


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.
Minimum of five (5) years administrative experience in Quality Management Utilization Management.
Working knowledge of facilitation, sentinel event/root cause analysis, and/or failure mode effects analysis (FMEA) skills.
Excellent interpersonal, presentation and communication skills.

Job Description

Coordinates, integrates and implements activities related to Quality Management/ Performance Improvement to achieve clinical goals and strategic operating plans and objectives. Promotes effective patient safety and performance improvement initiatives to improve processes and outcomes of patient care. Ensures institutional compliance with regulatory agencies in accordance with rules and regulations. Communicates quality initiatives and establishes processes for constant survey readiness.

Responsibilities Include:
1. Coordinates and implements the Quality Management/Performance Improvement Program at the facility.
Conducts orientation and 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.
Collaborates with the Medical Director to develop Performance Improvement Coordinating Group (PICG) agenda ensuring maximization of performance improvement initiatives.
Co-chairs facility PICG committee with Medical Director and participates in Safety committee meetings to promote performance improvement and risk reduction techniques to improve patient safety/quality outcomes.
2. 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.
3. 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).
4. 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.
5. Performs related duties, as required.

Associated topics: assistant director, care manager, director, director of nursing, lead, manager, nmh, officer, rgn, supervisor

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