Reporting to the Regional Director, Stroke Program is responsible for all operational aspects and evaluation of the Stroke Program. The Manager, Stroke Program will coordinate and collaborate with those departments that care for the stroke patient across the continuum of care.
Uses advanced skills in quality assessment to perform comprehensive quality of care and service audits that develop validated care standards, data repositories, and outcome measurements related to the care of stroke patients. Collects and analyzes benchmarking data, focus studies, and clinical indicators. Provides education, ensures loop closure, prepares reports, presents outcomes and participates in organizational-wide continuous improvement projects as it relates to Comprehensive Stroke Program performance.
Abstracts and enters data into data management systems as requested to support the program. Facilitates identification and documentation of hospital-based, database, and Comprehensive Stroke Program approved performance improvement variances and complications. Develops and assists others in developing action plans for process improvement and ensures follow through on these plans.
Coordinates the internal stroke QA meetings and maintain minutes Assists with the development and coordination of projects that will enhance the Stroke Program. Assesses the need for and facilitates the development of stroke protocols, guidelines, pathways, and standard order sets. Generates annual report information regarding activities and prepares statistical data.
Maintains updated knowledge of all regulatory standards and communicates to responsible parties, especially of the Det Norske Veritas (DNV) requirements for the certification of Comprehensive Stroke Centers. Demonstrates an advanced understanding of stroke-related procedures and stroke patient care including standards of care as well as potential injury complications. Completes case reviews and analyses for contributing factors to the variance in care and/or complications including all readmissions, IV tPA administration encounter metrics, required procedure/patient logs, IR procedure encounter metrics, deaths and complications.
Obtains and reports post-discharge functional scale data from patients as required by DNV. Obtains and reports patient satisfaction data as required by DNV. Participates in DNV survey activates as required.
Brings all opportunities for program improvement noted from data review to the attention of the program director in a timely, appropriate manner. Refers any repetitive physician/resident clinical or documentation outliers to the stroke program peer review process. Participates in outreach and community education programs Performs other duties as assigned.
Qualifications/Requirements:
Minimum of 5 years of clinical experience, required Experience with data collection, entry & analysis, required 2 years of program management experience, preferred
Graduate from an accredited school of nursing, required Licenses /
Current NYS RN Licensure, required. Other: Strong ability to facilitate group process, develop and prioritize goals and manage objectives