Associate Director Quality Assurance

Found in: Appcast Linkedin GBL C2 - 2 weeks ago

New York, United States NYC Health + Hospitals Full time

About NYC Health + Hospitals:


Since 1875, South Brooklyn Health has established its reputation for clinical excellence and culturally competent care. It has designations as a Certified Percutaneous Coronary Intervention (PCI) Center, an Advanced Primary Stroke Center, an accredited Baby-Friendly Hospital, a U.S. News & World Report high performing hospital. The hospital's staff is as diverse as the patients they serve. Interpreter services can be provided at any time of the day or night in over 130 languages.


At NYC Health + Hospitals, our mission is to deliver high quality care health services, without exception. Every employee takes a person-centered approach that exemplifies the ICARE values (Integrity, Compassion, Accountability, Respect, and Excellence) through empathic communication and partnerships between all persons.


Job Description:

Shift: Tour 2: 9 A.M. - 5 P.M.

Purpose:

Under general supervision, develops and maintains systems for monitoring standards for professional activities as mandated under Federal and State legislation. Provides guidance and advice with respect to policies and priorities in the development of Quality Assurance. The Associate Director of Quality Assurance reports to the Director of Quality.

Specific Duties and Responsibilities:

The Associate Director of Quality Assurance is charged with and responsible for:

  1. Serve as the CMS HARP administrator of South Brooklyn Health.
  2. Direct oversight of quality assurance and all Core Measure abstractions.
  3. Oversight of all third-party vendors who assist in transferring core measures data from medical record documentation, utilizing the Premier system.
  4. Oversight of abstractors staff and responsible for their continuous training.
  5. Responsible for providing data submitted to Q-HIP, and the QAPI Board Report.
  6. Oversight of the data management and analysis submitted to regulatory agencies including DOH, CMS, and Joint Commission as well as internal projects.
  7. Helps identify areas of vulnerability related to continuous compliance, performance improvement, and patient safety.
  8. Investigates patient care and safety incidents, and report to the appropriate regulatory agencies.
  9. Makes recommendations relating to the prevention of such incidents and determines quality control measures to foster a culture of safety for patients, staff, and visitors.
  10. Oversight of DOH and CMS Sepsis Program including:
  11. Ensuring DOH Sepsis abstraction and reporting
  12. Provide attending level data report for CMS Sepsis to Sepsis Champion
  13. Oversight of Sepsis monthly ED meetings and performance improvement initiatives.
  14. Coordinate DOH Sepsis submission and correction of Exception Reports.
  15. Develop monitoring tools based on Federal, State, Joint Commission, H&H, and hospital requirements.
  16. Submit reports of monitoring findings.
  17. As necessary, provide feedback and education to appropriate Providers and other staff either concurrently, during education and feedback sessions, or during other meeting sessions.
  18. Responsible for providing data for different projects:
  19. Provide input in regard to reviewing methodology and/or data sources.
  20. As required, develop monitoring tools.
  21. As required conduct or coordinate medical record reviews.
  22. As required, submit reports of monitoring findings.
  23. As necessary, provide feedback and education to appropriate providers either concurrently, during education and feedback sessions, or during meeting sessions.
  24. Participate in Committees and departmental meetings, as required.
  25. Serve as a member of departmental quality committees, as required.
  26. Participate in Clinical Department QAPI meetings, Quality Management Department meetings, and staff meetings, as required.
  27. Coordinate activities with the Director of Quality Assurance to ensure coverage for meetings, etc.
  28. Coordinate corrective action and process improvement projects. Work independently and within a team environment with solid follow-up, organization, prioritization skills, and attention to detail.
  29. Problem-solving using IHI tools; develop standard work, write policies and procedures, job aids, and business process communications.
  30. Assists in assessing organization compliance with accreditation standards and regulations by performing weekly tracer rounds or as required.
  31. Provides regulatory data reports and analysis.
  32. Lead and active participant in a regulatory tracer team. Performs regulatory mock tracers based on the established schedule or as needed
  33. Responsible for keeping track of regulatory events to facilitate the QAPI board book and QCEC regulatory reports.
  34. Accountable for required documentation and data gathering to maintain an updated Joint Commission binder.
  35. Provides education and assists with interpretation of TJC standards and CMS conditions of participation.
  36. Facilitates announced and unannounced regulatory agencies visits.
  37. Develop and provide presentations as needed/assigned.
  38. Other duties as assigned.


Minimum Qualifications:

* Qualification for Central Office.

# Qualification for Health Care Facility.

1. a. A Baccalaureate Degree in Public Administration, Public Health or Health Care Specialization; and,

b. Five* years or four# years of increasingly responsible experience in hospital administration, with particular emphasis on development and evaluation of health care delivery services; or,

2. a. A Masters Degree in Public Administration, Public Health or Health Care Specialization; and,

b. Four* years or three# years of increasingly responsible experience in hospital administration, with particular emphasis on development and evaluation of health care delivery services.


NYC Health and Hospitals offers a competitive benefits package that includes:

  • Comprehensive Health Benefits for employees hired to work 20+ hrs. per week
  • Retirement Savings and Pension Plans
  • Loan Forgiveness Programs for eligible employees
  • Paid Holidays and Vacation in accordance with employees' Collectively bargained contracts
  • College tuition discounts and professional development opportunities
  • Multiple employee discounts programs

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