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Vice President of Quality and Performance Improvement

Facility: St Francis Hospital Location: Roslyn, NY Department: Performance Improvement Category: Leadership Schedule: Full Time Shift: Day shift ReqNum: 6017069

St. Francis Hospital, The Heart Center is New York State's only specialty designated cardiac center. A member of Catholic Health Services of Long Island, St. Francis is consistently recognized by U.S. News & World Report as a national leader for Cardiology & Heart Surgery, as well as for Gastroenterology & GI Surgery. Additionally, U.S. News rates St. Francis as high performing in Geriatrics, Neurology & Neurosurgery, Orthopedics, and Pulmonology. Nursing care at St. Francis is also nationally recognized, with multiple Magnet designations, as well as the AMSN PRISM Awards and Beacon Awards. St. Francis has regularly out-scored other hospitals on Long Island.

St. Francis Hospital is dedicated to providing a supportive environment, committed to the highest standards of patient care, where health care professionals can develop their expertise and strengthen their credentials.

The Vice President of Quality, Regulatory and Performance Improvement (PI) at St. Francis Hospital reports to the Chief Medical Officer and is responsible for the administration of all programs and initiatives relating to quality, including publically reported and commercial quality metrics, and serves as a resource for Process Improvement throughout the organization, while ensuring full compliance with all accreditation and regulatory requirements. The successful candidate will plan, organize and direct the following functions including, but not limited to:

Abstracting data for reporting to Federal, State and accrediting agencies to include:

  • Core measures abstraction and validation (inpatient and outpatient), The Joint Commission and CMS
  • Abstraction and validation of data submitted to PCI, Open Heart, TAVR, ICD and CMS Carotid Artery Stent registries
  • Abstraction and validation of data for submission to NYSDOH and to AHA Get With the Guidelines

Assisting with data analysis and data display to:

  • Assure timely and complete submission of data to the above registries
  • Develop high level reports and scorecards for Hospital and Medical Staff leadership
  • Organize and prepare data for use in Focus and Ongoing Professional Practice Evaluation by Medical Staff
  • Directs a comprehensive Performance Improvement/Patient Safety Program
  • Recommends projects for improvement and sets appropriate targets related to PI
  • Actively participates in the development and execution of Hospital and CHS Patient Safety goals
  • Serves as the Hospital's liaison to The Joint Commission and other agencies as appropriate
  • Actively facilitates and/or participates in system and hospital-wide committees as appropriate
  • Prepares for and coordinates all activities related to accreditation and regulatory surveys
  • Provides oversight and direction related to employee orientation and educational requirements in conjunction with Nursing Education and Human Resources with regard to PI, TJC and regulatory agency requirements
  • Annually reviews the scope of the Hospital's PI Program and makes appropriate recommendations, updates, etc.
  • Participates in the development of Hospital PI teams and initiatives; assists with setting targets, goals, and the development of policies and procedures
  • Promotes a culture that is positive, that values individual strengths, and is committed to optimal patient care
  • Facilitates the growth of hospital knowledge regarding quality and high reliability, including the dissemination and implementation of "best practices" across the facility
  • Leads the facility-wide standardization in targeted process improvement initiatives, and evaluates success through pre-established criteria and measurement tools
  • Leads proactive patient safety activities to help create facilities that are high reliability organizations, as reflected in reduced errors, elimination of unsafe processes, and increased involvement of staff and physicians toward a culture of safety
  • Participates in regular analysis of facility quality and risk performance data, and plans steps based on data analysis for ongoing improvement
  • Serves as a regulatory resource regarding State and Federal regulations and standards, including but not limited to, CMS, NYS, and CDC. Stays current with NQF, AHRQ, Leapfrog, IHI and other quality performance initiatives.
  • Partners effectively with operational, functional and physician leaders to drive performance improvement across the organization
  • Maintains accountability for staffing, budgeting, staff development and engagement

Minimum Requirements:

  • Baccalaureate degree (clinical background required; licenses where appropriate) Master's degree preferred
  • 7-10 years of experience in a hospital inpatient setting with a strong background in quality management and PI
  • CPHQ strongly preferred
  • Six Sigma Trained/Certified
  • Knowledge and experience in quality infrastructure, implementation of decision tools, clinical protocols and guidelines and outcome measurement assessment
  • Expertise with MS Outlook, Word, Excel, and PowerPoint required

At Catholic Health Services of Long Island your well-being comes first, with comprehensive compensation and benefits; our offerings go beyond the basics. In addition to multiple medical plans, life insurance, generous paid time off and flexible spending accounts, we also offer substantial tuition reimbursement, an employer funded pension plan and several savings plan options for your future.

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