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Assistant Director, Quality Management

North Shore-LIJ Health System Type Full time Posted 7/16/2014
Salary - n/a - Starts 9/13/2014
NY - New York (All) - New Hyde Park Referral - n/a -    
Assistant Director, Quality Management
As the Quality Management Assistant Director, you will implement North Shore LIJ's philosophy, goals and objectives by assisting in the development of a multidisciplinary Performance Improvement Program that focuses on regulatory preparation, policy/procedure standardization, measurements and performance improvement initiatives/activities within the hospital. 
Responsibilities include:
1. Monitors and maintains institutional compliance with governmental/regulatory rules and regulations.
  • Coordinates plans of correction for Statement of Deficiencies.
  • Forms and staffs committees to assess and ensure compliance with plans for corrective action.
  • Oversees DOH survey activity related to patient complaints and coordinates responses to all Statements of Deficiency.
  • Coordinates all incidents reporting to the NYS Department of Health in accordance with regulatory requirements as set forth in section 405.8 of the Codes, Rules and Regulations of the State of New York.
  • Coordinates all reporting as required under the Safety Medical Device Act.
2. Acts as a resource person and educates hospital personnel about risk management related medical, legal and regulatory issues.
  • Participates in various committees of the Medical Center and /or Health System including, but not limited to the PICC Committee, Safety Committee and Medication Variation Committee.
  • Serves as a survey coordinator to the New York State Department of Health, JCAHO, and other governmental and regulatory agencies during on-site inspections and surveys.
  • Participates in and/or coordinates root cause analysis as required under the JCAHO Sentinel Event Reporting Policy.
3. Develops systems and procedures to carry out QM/PI functions.
  • Participates in Department/Service PI Hospital committees, task forces, and organizational performance improvement teams as appropriate.
  • Recommends selected focus studies to evaluate and improve quality patient care.
  • Keeps abreast of new and revised regulatory agency requirements.
4. Collaborates with the multidisciplinary health care team regarding development and implementation of the QM program.
  • Serves as a consultant to the multidisciplinary Department/Service PI Committee.
  • Participates in the Hospital employee orientation in the absence of Director.
  • Recommends topics for review, including (but not limited to) high risk, high volume or problem-prone activities, facilitating the performance improvement framework for all projects.
  • Provides education to the multidisciplinary Department/Service to accomplish the goals and techniques of Performance Improvement.
  • Collaborates with health care professionals within the hospital to identify areas for prioritization and ensure optimal appropriateness and quality of patient services are rendered.
5. Assists in the preparation process for accreditation and regulatory surveys.
  • Demonstrates familiarity with standards of accreditation and regulatory agencies.  Assists with assessment of adherence to these standards.
  • Makes judgments regarding incident reporting as appropriate to State and Federal agencies required by laws, regulation or other licensing bodies.
  • Monitors and evaluates results of surveys as it related to PI opportunities.
  • Monitors Hospital compliance with external regulatory agencies.
6. Supports an information system for the data aggregation for Risk/Quality Management.
  • Timely collection and maintenance of information from different sources, including (but not limited to) past claims, incident reports, and patient complaints.
  • Ensures the integration of Quality Management activities with Risk Management and ongoing evaluation, including monitoring of appropriate corrective actions/improvements to ensure resolution.
7. Manages and supports Risk Management database.
  • Reviews and screens all occurrence reports.
  • Maintains and supports the DOH database.
  • Tabulates, analyzes and trends data.
  • Reports significant findings as necessary.

  • Master's Degree in Nursing, required. 
  • Ph.D., preferred.
  • Current license to practice as a Registered Professional Nurse in New York State.
  • Minimum of three (3) years nursing experience in quality management and leadership, including previous supervisory experience.
  • Knowledge of third party payers, State and Federal regulations, preferred.
Our Culture    
Transforming care, optimizing patient satisfaction and creating better patient outcomes are just some of the things our talented team members are doing at North Shore-LIJ each and every day. As a culture committed to providing our customers with the highest quality service, we stand behind our core values: Patients first; Caring; Excellence; Innovation; Integrity and Teamwork. It is our commitment and our culture that sets us apart from others and is the cornerstone of everything we do. Join an organization whose team members are valued, cared for and offered continuous opportunities to grow. Click on the link to learn more about us: www.northshorelij.com/goals
Please note: North Shore-LIJ is a smoke-free environment. Smoking and the use of tobacco products is strictly prohibited anywhere on campus, including parking lots and outdoor areas on the premises. Free smoking cessation programs and quit medications are offered to team members who wish to quit through the North Shore-LIJ Center for Tobacco Control.