Reporting to the Regional Director, Stroke Program, and the Regional Manager, Stroke Program is responsible for all operational aspects and evaluation of the Stroke Programs at HAHV and MHRH. The Regional Manager, Stroke Program will coordinate and collaborate with those departments that care for the stroke patient across the continuum of care.
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.
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.
Abstracts and enters data into data management systems as requested to support the program.
Facilitates identification and documentation of hospital-based, database, and Comprehensive Stroke Program approved performance improvement variances and complications.
Develops and assists others in developing action plans for process improvement and ensures follow through on these plans.
Coordinates the internal stroke QA meetings and maintain minutes
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.
Assists with the development and coordination of projects that will enhance the Stroke Program.
Assesses the need for and facilitates the development of stroke protocols, guidelines, pathways, and standard order sets.
Generates annual report information regarding activities and prepares statistical data.
Participates in stroke-related research by providing data to investigators in compliance with HIPPA and all applicable, regulatory, State, and Department of Health regulations.
Maintains updated knowledge of all regulatory standards and communicates to responsible parties, especially of the Det Norske Veritas (DNV) requirements for the certification of Comprehensive Stroke Centers.
Demonstrates an advanced understanding of stroke-related procedures and stroke patient care including standards of care as well as potential injury complications.
Completes case reviews and analyses for contributing factors to the variance in care and/or complications including all readmissions, IV tPA administration encounter metrics, required procedure/patient logs, IR procedure encounter metrics, deaths and complications.
Obtains and reports post-discharge functional scale data from patients as required by DNV.
Obtains and reports patient satisfaction data as required by DNV.
Participates in DNV survey activates as required.
Brings all opportunities for program improvement noted from data review to the attention of the program director in a timely, appropriate manner.
Refers any repetitive physician/resident clinical or documentation outliers to the stroke program peer review process.
Participates in outreach and community education programs
Performs other duties as assigned.
3-5 years of progressive experience managing a clinical program required. Experience in data collection, entry, and analysis required.
AND, required. BSN, preferred.
Licenses / Certifications:
Current NYS RN Licensure, required.
Strong ability to facilitate group process, develop and prioritize goals and manage objectives.
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.