Stroke Certification Coordinator-Clinical Compliance

5 hours ago

Mobile, United States USA Health Full time

Overview USA Health is Transforming Medicine along the Gulf Coast to care for the unique needs of our community. USA Health is changing how medical care, education, and research impact the health of people who live in Mobile and the surrounding area. Our team of doctors, advanced care providers, nurses, therapists, and researchers provide the region's most advanced medicine at multiple facilities, campuses, clinics, and classrooms. We offer patients convenient access to innovative treatments and advancements that improve the health and overall wellbeing of our community. Responsibilities Collaborates with the Stroke Medical Director to review institutional activities related to stroke care, guidelines, policies, and certification; coordinates and directs the Stroke Quality Improvement (QI) plan and program; collaborates with medical staff, nursing, ancillary departments, and care management to ensure stroke patient care meets the standards; performs patient rounds with the stroke team and participates in weekly stroke conferences as needed; participates in local, state, and national activities pertaining to stroke care; coordinates stroke activities including stroke committee meetings, stroke support groups, and data entry of stroke patient information; manages stroke program accreditation, hospital staff education, patient education, community education, and related activities; develops stroke patient treatment protocols based on evidence-based practice guidelines; maintains knowledge competency in stroke care and Joint Commission certification; completes the Stroke Certification application and submits monitoring data; ensures survey readiness for the stroke certification site visit, and acts as a liaison for stroke surveys; assists the Hospital Accreditation Coordinator with stroke certification/Joint Commission activities (e.g., Patient and data tracers); analyzes QI data for trends and prepares reports for the stroke committee; facilitates resident education on stroke program PI measures with the American Heart Association's Get With the Guidelines (GWTG) program; organizes and reports QI data for use in the PI Program and in external and internal benchmarking programs according to the hospitals Stroke PI Plan; abstracts and enters the Stroke Core Measures data into the GWTG web-based software program; validates electronic clinical quality measures (eCQM) and meaningful use (MU) data for stroke patients; collaborates with the health services information system (HSIS) department in building or revising the electronic medical record, as needed; promotes community-wide education regarding stroke and TIA; monitors the hospital's compliance with National Patient Safety Goals; provides orientation and annual education on stroke care; coordinates the tracking of required stroke education for all stroke caregivers as required by the stroke statewide system; validates neurology resident and attending education for the NIHSS training upon hire and on a biannual basis; checks for new stroke admissions daily and rounds to ensure that stroke measures are being followed; takes appropriate action to ensure meeting required indicators for GWTG and Joint Commission measures of quality care; conducts inter-rater reliability audits for the heart failure GWTG program; communicates and uses appropriate customer relation skills with physicians, patients, families, and co-workers in person and via telephone; responds to pages, texts, and emails in a timely manner; utilizes group notification to communicate hospital-wide that surveyors have arrived for survey; communicates with the Director/Assistant Director regarding activities to meet continuous survey standards readiness; communicates recommendations for process improvements to Department Managers to meet standards and improve quality and safety of patient care; communicates the results and fallouts from monitoring results related to the stroke standards compliance to managers; maintains accurate, complete, and confidential information utilized in the hospital Performance Improvement program; maintains documentation for the unannounced stroke site visit; prepares action plans and responses related to recommendations for improvement related to survey findings for submission to The Joint Commission; prepares reports related to survey tracer findings, mock survey outcomes, Joint Commission monitoring requirements, RCA's, and intra-cycle monitoring; accepts and completes all duties positively and without conflict; helps others and improves the performance of the QM department; completes all mandatory department educational and hospital requirements; utilizes cost-effective practices in performing all aspects of the job; adheres to current Infection Control and Safety standards; plans, collects, organizes, and reports QA data for use in the PI program and in external and internal benchmarking programs according to the hospital's PI Plan; liaises with Risk Management and the Patient Safety Officer in relaying potential risk issues; maintains current knowledge of the Joint Commission (TJC) CMS standards for stroke certification survey; serves as a member of various committees as directed; advises department heads in quality care planning, monitoring, education, and evaluation activities; uses internet, email, databases, spreadsheets, word processing, and presentation programs; provides education regarding Joint Commission and Performance Improvement activities to healthcare staff audiences; develops tools to assist in performance measurement and assists the organization in identifying improvement opportunities; abides by and enforces all compliance requirements and policies and performs these responsibilities in an ethical manner consistent with the organization's values; adheres to policies pertaining to confidentiality; maintains regular and prompt attendance; ability to work the assigned schedule and overtime as required; requires minimal supervision to provide support for the PI program; completes related duties as required. Qualifications Bachelor's degree in nursing, allied health, or a related field from an accredited institution as approved by the University of South Alabama. Four years of related experience and current licensure in a clinical field. A Master's degree is preferred and may substitute for up to one year of the required experience. Experience in a stroke center is preferred. Hospital performance improvement experience, healthcare research, or data collection analysis presentation is preferred. Equal Employment Opportunity/Affirmative Action Employer USA Health is an EO/AA employer and does not discriminate on the basis of race, color, national origin, sex, pregnancy, sexual orientation, gender identity, gender expression, religion, age, genetic information, disability, protected veteran status, or any other applicable legally-protected basis. J-18808-Ljbffr

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