Job Description
The Coordinator Performance Improvement/Risk Management is responsible for assisting the AVP Hospital Performance Improvement/Risk Management in overseeing, planning, and implementing new and existing healthcare quality improvement initiatives and education programs; ensures maintenance of programs in accordance with prescribed quality standards; conducts data collection, reporting and monitoring for key performance measurement activities; and provides direction and implementation of all regulatory program review and accreditation surveys and federal/state QI compliance activities.
- Utilizes performance improvement model (Plan-Do-Study-Act) to improve patient outcomes
- Works with standing committees and department heads to accomplish objectives of Performance Improvement programs
- Participates in Hospital Acquired Conditions reduction activities, including surveillance and workgroups
- Review and analyze occurrences to determine the need for referrals to appropriate individuals for review.
- Participates in Risk Management activities including but not limited to internal and external RCAs as needed.
- Conducts and participates in regulatory program review and accreditation survey preparation and Mock Surveyors to constant state of readiness.
- Responsible for preparing and conducting Survey Readiness meetings as needed
- Manages all on-site regulatory and accreditation visits,
- Coordinates all activities surrounding the application and on-site readiness for Joint Commission, OASAS, DOH, etc. Certifications.
- Coordinates the formulation of a comprehensive Plan of Correction (POC) with relevant staff/leaders
- Ensures the monitoring of POCs and providing compliance feedback to stakeholders.
Requirements
- NYS RN license required. Bachelor’s degree required; master’s degree preferred.
- 1-3 years of related experience required.
- Strong verbal and written communication skills.
- Proficient in Microsoft Office Suite
- Knowledge of medical terminology, clinical concepts
- Knowledge of Hospital Regulatory process a plus
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