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 and supervisors by communicating and guiding toward achieving department objectives.
• Develops, communicates, and builds consensus for goals in alignment with the health system.
• Manages and implements the quality management and performance improvement programs for a healthcare facility.
• Ensures programs and services are implemented at the highest standards and patients receive the highest level of care.
• 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.
• Facilitates the performance improvement framework for all projects and collaborates with health care professionals within the hospital to identify areas for prioritization and ensure optimal appropriateness and quality of patient services are rendered.
• Monitors and evaluates results of surveys as it related to performance improvement opportunities.
• 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, and manages and supports risk management database; reviews and screens all occurrence reports.
• Oversees quality assurance and compliance functions.
• Responsible for monitoring and updating policies and procedures to include regulatory changes.
• 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

• Graduate from an accredited School of Nursing required.
• Current License to practice as a Registered Professional Nurse in New York State required, plus specialized certifications as needed.
• 6-8 years of relevant experience and 2-5 years of leadership / management experience, required.