Description:

MAIN FUNCTION

: Implement and lead best practice quality, performance improvement and risk management programs compliant with state and federal healthcare regulations. Report quality, patient experience, and risk management data to the Board of Directors. Serve as a facilitator and catalyst for improving organization quality and patient experience including cross functional/departmental initiatives. Serves as the Quality Manager, NYPORTS Coordinator, Patient Relations Co-Leader and Advocate and Patient Safety Officer. Works collaboratively with all Leadership, the Corporate Compliance Officer, the HIPAA Privacy and Security Officer and Directors and Chiefs of Medical Services.

REPORTS TO

Vice President of Physician Services and Quality, Noyes, and the Southern Regional Chief Medical Officer

DUTIES AND RESPONSIBILITIES

Quality Management :

Identifies opportunities to improve organizational clinical quality and efficiency. Serves as the primary leader and facilitator for Joint Commission accreditation readiness. Leads and facilitates Lean Team and performance improvement teams to work on P.I. initiatives. Develops systems to measure baseline quality data and measurable improvements. Identifies opportunities for Medical Staff performance improvement activities through the peer review process and works with the Chief Medical Officer to design and conduct those activities. Responsible for the coordination of and submission of quality data to CMS, hospital quality improvement programs (i.e. NSQIP, Get With the Guidelines, etc), and other insurers. Responsible for data abstraction, review, submission, and corrective action plans associated with Excellus

HPIP, TJC

ORYX and eCQMs, Vizient analytics and reporting, Medisolv, NDNQI, CDAC, Star ratings. Participates in UR Enterprise MERM and Quality Reporting programs and initiatives. Oversees Quality and Compliance Facilitator to abstract and report appropriate quality data. Oversees the patient safety program including incident reporting, root cause analyses, sentinel event reporting to NYPORTs, systems design, failure modes effect analysis, and proactive staff training and education Serves as the primary coordinator and lead for organizational RCAs.

Performance Improvement :

Leads organization wide performance improvement initiatives with the support of senior leadership. Supports unit and service line leaders in the identification of performance improvement metrics and plans. Prepares monthly and quarterly PI dashboards and reports for leadership, Quality and BOD reporting.

Patient Experience :

Receives and responds to patient feedback in the form of complaints, grievances, compliments. Works with managers and staff to enhance patient experience, respond to complaints and grievances and implement corrective actions in response to findings of related investigations. Escalates patient care issues as appropriate. Supervises and coordinates activities and performance improvement initiatives related to the patient experience. Serves as the organizational resource for patient experience training, setting goals, defining tactics and reporting on progress at the local and board level. Responsible for patient relations staff and effective handling of patient complaints with the goals of investigation, follow up, corrective action and response according to policy and overall performance improvement. Responsible for Press Ganey, CGCAHPS patient experience initiatives, performance improvement, report abstraction and presentation to internal stakeholders and leadership.

Risk Management :

Conducts periodic organizational risk assessments and leads JC tracer activities with scheduled consistency at minimum reviewing each clinical area once per quarter. Tracks results of JC tracer activities to identify organizational trends and to support ongoing patient safety and compliance. Responsible for post survey action planning, to include identification of specific corrective actions in collaboration with unit and service line leaders, and submission of the action plan to the regulatory body (i.e.

JC, DOH, CMS

etc) Coordinates activities associated with medical malpractice litigations. Tracks internal incident reporting to identify adverse trends. Reports appropriate incidents to the New York State Department of Health, develops NYPORTS action plans and ensures adherence with appropriate leaders and staff. Communications Organize, display and communicate findings/presentations targeting the needs of various audiences. Evaluate information and discerns critical nature of issues requiring immediate intervention and/or involvement by appropriate parties. Manage, coach and develop staff.

Requirements:

QUALIFICATIONS

: NYS licensed Registered Nurse (RN) or other clinical or allied health field (CSW, MSW) with a significant clinical experience and a Bachelor's degree required; master's and/or CPHQ preferred. Experience with hospital-wide performance improvement, clinical quality improvement, patient experience initiatives and risk management necessary. Knowledge of performance improvement tools and implementation skills. Knowledge of and experience working with statistics, data collection, analysis and data presentation. Strong presentation, analytical and computer skills required. Must have demonstrated effective collaborative efforts with administrative and clinical leadership.