I. POSITION SUMMARY The Program Manager is responsible for all operational aspects and evaluation of Westchester Medical Center's Comprehensive Stroke Program. This shall include but not be limited to program development, implementation, assessment, patient flow, and performance improvement initiatives. The Stroke Program Manager will coordinate and collaborate with those departments that care for the stroke patient across the continuum of care. The Program Manager will also be responsible for data abstraction and entry, stroke outreach, and ensuring that data related to primary and comprehensive stroke designations is appropriately entered, monitored and communicated to key stakeholders on a regular basis. There will be oversight and management of the stroke quality assurance program, quality data analysis and development of process improvement initiatives related to identified variances in the quality data. The Stroke Program Manager will ensure that the program maintains a regional presence as a stroke resource in the Hudson Valley region and will engage in activities to promote such a presence. II. PRINCIPAL RESPONSIBILITIES Data management A Enters data into data management systems as requested to support the program. Obtains and reports post-discharge functional scale data from patients as required by DNV. A Obtains and reports patient satisfaction data as required by relevant accreditation bodies. A Remains up to date on changes to Get With The Guidelines database and date requirements A Remains current on the responsibilities and accrediting requirements of designated comprehensive stroke Center A Provides monthly reports on all regulatory metrics A Uses advanced skills in quality assessment to perform comprehensive quality of care and service audits that develop validated care standards, data repositories, and outcome measurements related to the care of stroke patients. Regulatory duties A Maintains updated knowledge of all regulatory standards and communicates to responsible parties, especially of the Det Norske Veritas (DNV) and NY State requirements for the certification of Comprehensive Stroke Centers. A Participates in DNV survey activates as required. Quality Improvement A Facilitates identification and documentation of hospital-based, database, and Comprehensive Stroke Program approved performance improvement variances and complications. A Collects and analyzes benchmarking data, focus studies, and clinical indicators. Provides education, ensures loop closure, prepares reports, presents outcomes and participates in organizational-wide continuous improvement projects as it relates to Comprehensive Stroke Program performance. A Develops and assists others in developing action plans for process improvement and ensures follow through on these plans. A Assesses the need for and facilitates the development of stroke protocols, guidelines, pathways, and standard order sets. A Completes case reviews and analyses for contributing factors to the variance in care and/or complications including all readmissions, IV t-PA administration encounter metrics, required procedure/patient logs, IR procedure encounter metrics, deaths and complications. A Brings all opportunities for program improvement noted from data review to the attention of the program director in a timely, appropriate manner. Organizational duties A Coordinates the internal stroke QA meetings and maintain minutes A Works in collaboration with clinical teams, leadership, executive committees, etc. to evaluate the effectiveness and appropriateness of care and the development of policies and procedures. A Assists with the development and coordination of projects that will enhance the Stroke Program. A Participate in outreach and community education programs Clinical duties A Demonstrates an advanced understanding of stroke-related procedures and stroke patient care including standards of care as well as potential injury complications. A Participates in stroke-related research by providing data to investigators in compliance with HIPPA and all applicable, regulatory, State, and Department of Health regulations. A Refers any repetitive physician/resident clinical or documentation outliers to the stroke program peer review process. A Performs other duties as assigned. III. POSITION REQUIREMENTS A Clinical license required, RN preferred A Experience in data collection, entry, and analysis required. A Strong ability to facilitate group process, develop and prioritize goals and manage objectives. A 3-5 years of progressive experience managing a stroke program required; one year in a management/ supervisory role in a large tertiary academic hospital preferred
WMCHealth is a 1,900-bed healthcare system headquartered in Valhalla, New York, with ten hospitals on eight campuses spanning 6,200 square miles of the Hudson Valley. WMCHealth employs more than 12,000 people and has nearly 3,000 attending physicians. From Level 1, Level 2 and Pediatric Trauma Centers, the region’s only acute care children’s hospital, an academic medical center, several community hospitals, dozens of specialized institutes and centers, a state of the art Telemedicine program, skilled nursing, assisted living facilities, homecare services and one of the largest mental health systems in New York State, today WMCHealth is the pre-eminent provider of integrated healthcare in the Hudson Valley.