RESPONSIBILITIES:

• Demonstrates knowledge of the key elements for a successful performance improvement program and the ability to develop, implement and evaluate quality improvement plans.
• Demonstrates understanding of Performance Improvement methodology, statistical analysis in the healthcare setting, and renders technical assistance to departmental leaders in the preparation and analysis of data.
• Works collaboratively with other components of care delivery (i.e. Nursing, Ancillary/Support Services, and Medical Staff Office) to ensure that a coordinated and comprehensive quality program is implemented, continually assessed, and standards are being met and/or exceeded.
• Performs tracers and environmental rounding to maintain a state of continuous service readiness for regulatory surveys.
• Oversees the completion of required action plans and ensures ongoing assessment and compliance.
• Maintains confidentiality of all quality/performance improvement documents, data, and meeting discussions.
• Provides leadership during a Sentinel Event Process and Root Cause Analysis.
• Assist in the development, compliance, and monitoring of quality initiatives related to The Joint Commission, NYSDOH, Disease Initiatives, CMS, Qhip, HANYS/EQIC and other regulatory agencies.
• Demonstrates self-motivation and direction, ability to assess problems encountered, and to implement solutions for those needs.
• Functions as leader and resource for delivery of quality care.
• Works as a team member to complete local system and departmental projects, solve problems, and resolve conflicts.
• Shows a high level of professionalism, courtesy, and positive behavior during interactions with other employees, visitors, patients, and regulatory agencies.
• Manages assigned projects within the facility in an organized, professional, and timely manner, including developing work plans, ongoing evaluation of progress, and reporting the results and reasons for variances to appropriate leadership.
• Performs other duties as assigned.

• 
  

  QUALIFICATIONS / REQUIREMENTS:

  Experience:

  Minimum: 5 years of experience in nursing. Experience in healthcare setting with extensive knowledge of healthcare regulatory requirements and quality improvement initiatives.

  Education:

  Bachelor's degree in Nursing

  Licenses / Certifications:

  Current NYS Nursing license

  Other: If applicable, the individual performing this job may reasonably anticipate coming into contact with human blood and other potentially infectious materials. Individuals in this position are required to exercise universal precautions, use personal protective equipment and devices, and learn the policies concerning infection control.