Facilitates and participates-in the implementation of the multidisciplinary hospital-wide Quality Assurance (QM)/Performance Improvement (PI) program. Promotes collaborative practice among departments/services for improved clinical outcomes and processes of care.Plans and implements a systemic process to monitor the quality and appropriateness of patient care
1.Supports an information system for Quality Management data aggregation.
·Maintains Quality Management and NYPORTS database.
·Provides Department Chairman and Quality Management/ Performance Improvement Committees with data analysis of trends, including high-risk patients/ procedures.
·Coordinates Root Cause Analysis and reports results to appropriate departments and regulatory agencies.
·Evaluates risk management activities including monitoring of appropriate corrective actions/ improvements to render quality health care in all related phases.
·Monitors statistical data from Quality Management reports and evaluations.
2.Develops systems and procedures to carry out QM/PI functions.
·Assists in the implementation of the philosophy, goals, and objectives of the Hospital.
·Participates in departmental/service Quality Improvement committees, task forces and organizational performance improvement teams as appropriate.
·Participates in program planning and development.
3.Collaborates with the multidisciplinary health care team regarding development and implementation of QM/PI program.
·Serves as a consultant to the multidisciplinary department/service Quality Improvement Committees.
·Participates as a member of the institutional Quality Management/ Performance Improvement committees in planning, reviewing, and implementing activities related to the organizational goals and objectives.
·Recommends topics for review, including but not limited to, high risk, high volume, or problem prone activities.
4.Assists in the preparation process for accreditation and regulatory surveys.
·Uses knowledge of standards of accreditation and regulatory agencies to advise and assists with assessment of adherence.
·Maintains an effective reporting system (i.e. QM database and NYPORTS database) to communicate and document findings, action and follow-up resulting from systematic monitoring and evaluation criteria.
5.Performs related duties, as required.
*ADA Essential Functions