POSITION SUMMARY:

The work involves coordinating all activities involved in the delivery of safe and high quality patient care within a hospital health center. This employee will be responsible for developing and implementing programs, and the identification and resolution of problems, associated with patient safety and quality management. This position involves significant interdepartmental collaboration and knowledge of electronic health records and other data systems. The employee interprets regulatory and accreditation standards, reports on data obtained related to these standards, and conducts educational programs for hospital employees and members of the medical staff. The work is performed under the general direction of the Chief Medical Officer and the Chairman of the Quality Assurance Committee and involves supervision of subordinate staff. Does related work as required.

POSITION SPECIFIC PERFORMANCE STANDARDS:

• Assesses the quality of medical care provided by hospital employees by reviewing medical records, assisting in monitoring a variety of medical functions such as blood utilization, tissue review and mortality review.
• Reviews DRG data analysis to identify potential problem areas and profit/loss areas for financial management.
• Distributes and interprets DRG data and utilization review requirements to administration, finance, physicians and clinical departments.
• Plans, develops and conducts DRG educational programs for medical staff and hospital employees.
• Assists the medical, nursing and professional staff in developing criteria by which problem areas can be identified, assessed and resolved.
• Writes a quality assurance plan and prepares methods for continued assessment or evaluation on the effectiveness of current quality assurance activities.
• Prepares and distributes reports on results of quality assurance activities which will include recommendations to resolve identified problems.
• Assists professional and medical staff in developing criteria for prioritizing identified problems in the quality of care provided patients.
• Maintains continuity in the analysis of activities, documentation of information and data, follow-up activities to improve the quality of care and completion of reporting functions.
• Attends all medical staff committee and other departmental and committee meetings affecting quality assurance problems and activities affecting the monitoring and resolution of identified problems.
• Reviews and integrates quality assurance plans prepared for and used in various departments within the hospital to eliminate duplication of effort, improve communications and reduce costs.
• Follows up on all activities performed in compliance with quality assurance plans and makes recommendations or performs corrective action.

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QUALIFICATIONS:

Education: Graduation from a regionally accredited or NYS Registered College or University with a Bachelor's Degree in Nursing and two years of professional experience in the development and implementation of clinical quality assurance and performance improvement policies and procedures, as well as the preparation and maintenance of corresponding records; or Graduation from a regionally accredited or NYS Registered two year college with an Associate’s Degree in Nursing or Registered Nurse Diploma Program and four years of related professional experience, at least two of which must have involved the development and implementation of clinical quality assurance, performance improvement policies and procedures, as well as the preparation and maintenance of corresponding records; or An equivalent combination of training and experience within the limits of 1 and 2.

Experience: At least 3-5 years of relevant acute-care hospital experience in quality, patient safety, regulatory and accreditation, or performance improvement. Knowledgeable and experienced in Lean, Six Sigma, PDSA or other performance improvement methods, with record of successful improvement projects. Strong record of leadership, project management, collaboration. Demonstrated analytic and computer skills, with strong writing, problem solving, and communication skill

Licensure: Possession of a CPHQ Credential (Certified Professional in Healthcare Quality) from NAHQ (National Association of Healthcare Quality) preferred.