Manager, Stroke Quality Program

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The role of Stroke Program Manager is one of educator, collaborator, subject matter expert and change agent. In conjunction with the Stroke Program  Medical Director, and Physician Leads, the Stroke  Program Manager maintains and implements new Standards, Elements of Performance and recommendations from The Joint Commission (TJC) and the American Stroke Association – Get With the Guidelines (AHA-GWTG) as well as knowledge of evidence-based practice changes. The incumbent will be responsible for overseeing and providing overall leadership of the stroke program. The Manager is responsible for continuous accreditation readiness activities and quality assurance activities for the health system in close collaboration with senior management within the Department, and other identified leaders. This includes the frequent and ongoing identification and monitoring of quality indicators and outcomes, coordinating and analyzing data, and establishing and achieving hospital wide as well as department specific objectives of the programs consistent with the mission and vision of the organization. Facilitates continuous collaboration with the risk management and safety programs, as well as compliance with TJC standards and other regulatory agencies.

• Clinical Practice including advanced assessment skills, facilitates Evidence Based Practice across all disciplines in accordance with the most current and up-to-date Stroke Guidelines, acts as a resource for staff and providers in developing and implementing a plan of care, maintains current knowledge and competency in the management of stroke patients in professional practice.

• Maintains a written Stroke Management Plan, along with related policies and procedures, consistent with the mission and vision of the organization and in compliance with the TJC and other regulatory agency standards.

• Conducts reviews of the effectiveness of the Stroke Management Plan and related Policies and Procedures, and reviews and revises the Plan, its Program Goals and Objectives, and all related Policies and Procedures as necessary.

• Participates in the development of, and continuously monitors, an internal reporting structure for quality management and related activities under the direction of senior management. Ensures the timely reporting of quality data to appropriate individuals through a systematic and defined multidisciplinary process.

• Assists committees and departments with PI planning, organization, design of monitoring systems, implementation of study topics and follow-up activity, as necessary. Coordinates timely reporting through a defined, formal reporting structure.

• Educates faculty, administration and staff in the identification of opportunities for improvement and methods of collecting, analyzing, and reporting of findings and improvement strategies.

• Identifies learning needs of professional staff and patients, provides education to advance staff, patient, and their families’ knowledge, collaborates in the development and implementation of the interdisciplinary education plan.

• Collaborates with Information Technology, Risk Management, Regulatory Compliance, Healthcare Quality, and Environment of Care Safety Officer in the identification of opportunities for improvement in the areas of clinical quality and patient safety.

• Manages the timely submission of patient care data into AHA-GWTG Stroke Registry for TJC. Analyzes findings and implements appropriate interventions to demonstrate improvements in quality outcomes.

• Participates in the creation and ensures the effectiveness of efficient systems, primarily those having a direct impact on the health care system enterprise and patient care.

• Ensures regulatory agencies are contacted to proactively verify and clarify expectations, with Leadership approval.

• Works closely with senior management in the development, attainment, and evaluation of metrics /outcomes, and makes recommendations.

• Collaborate with a broad range of clinicians and professionals on quality improvement initiatives and quality of service provided and take responsibility to lead the implementation of quality improvement initiatives for the assi