Patient Complaints Investigated & Resolved within Regulatory Guidelines
- Oversees the Hospital inpatient and outpatient quality reporting programs data collection and complaints and grievances.
- Directs the Infection Control Process, which includes effective surveillance, actual and potential problem identification and resolution, and monitoring of clinical practice, and consistent reporting.
- Facilitates the investigation and resolution of patient complaints and grievances. Initiates and/or reviews correspondence to patient/family following established timelines.
- Collaborates with hospital Chief Medical Officer to actively participate in sustaining a medical staff that is knowledgeable of clinical outcomes, quality data and culture of transparency and patient safety, fosters collaboration among physicians and associates.
- Analyzes occurrence data for frequency and severity of events. Identifies trends necessitating intervention and works with leadership in planning and implementing actions to address identified issues. Tracks and reports to the FDA, and other entities, any medical device related events according to the requirements of the Safe Medical Device Act.
- Works with physicians and other client staff to identify an appropriate resolution to complaints.
Board is Aware and Approves of Performance Improvement Actions & Outcomes for the Delivery of Safe Patient Care
- Develops a comprehensive quality and patient safety plan to include specific measures and accountabilities and a comprehensive reporting program to demonstrate and anticipate outcomes to administration, leadership and management, including short term and long-term goals for quality improvement
- Oversees the quality program that incorporates the evaluation of quality across the continuum of care from outpatient setting to acute care inpatient setting, including coordinating the data collection, analysis and reporting processes and systems, policies and procedures for quality management.
- Directs and supervises maintenance of nursing department facilities, equipment, supplies, and areas, and assures compliance with established standards and regulatory requirements.Inspects all departmental areas on a regular basis and initiates corrective action and follow up.
- Develops annual quality plan.Reports monthly to management committee on quality.Reports quarterly to the Board on progress against plan.
Approved Budget and Productivity Standards
- Responsible for cost controls to insure maximum effectiveness of funds expended from approved departmental budgets.
- Oversees the development of operating and capital budget for assigned areas of responsibility and creates accountability for compliance of approved budget and productivity standards within each service.
- Establishes and promotes the appropriate structure for clinical nursing services by analyzing the efficiency and effectiveness of nursing allocations and deployments, ensuring that nursing services are well-coordinated with other clinical departments of the organization.
- Provides oversight of patient care resources; monitoring capital and operational budgets; establishing systems for proactive budget variance identification and correction.
- Ensures financial, material, people and technological resources are allocated to achieve optimal results.
Strategic Agility: Sees ahead clearly; can anticipate future consequences and trends accurately; has broad knowledge and perspective; is future oriented; can articulately paint credible pictures and visions of possibilities and likelihoods; can create competitive and breakthrough strategies and plans.
Building Organizational Talent: Anticipates talents, skills and knowledge that will be needed in the organization; seeks out opportunities to grow people’s capabilities to match those needs; improves the results of others by identifying areas of performance strengths and development opportunities, by providing coaching, mentoring or development opportunities, and by providing clear, behaviorally specific feedback to team members and subordinates; creates a learning environment that ensures associates realize their highest potential, allowing the organization as a whole to meet future challenges.
Driving Execution: Sets and maintains high performance standards for self and others that support the organization’s strategic plan and holds self and other team members accountable for achieving results; ensures organizational systems, processes and people are aligned to support strategic objectives; regularly evaluates self and team on goal attainment, processes used to achieve goals, and competitive benchmarks.
Managing Change: Helps employees develop a clear understanding of what they will need to do differently as a result of changes in the organization; establishes structures and processes to plan and manage the orderly implementation of change; helps individuals and groups manage the anxiety associated with significant change; facilitates groups or teams through the problem-solve and creative-thinking processes leading to the development and implementation of new approaches, systems, structures and methods.
Inclusion: Relates well to a wide variety of diverse styles, types and classes; open to differences; effective up, down, sideways, inside and outside; builds diverse networks; quick to find common ground; treats differences fairly and equitably; provides an environment where all employees feel welcome to contribute their full range of skills, ideas and opinions; demonstrates sensitivity to and respect for the diverse cultural backgrounds and practices of customers, regulatory agencies, and staff.
Total Work Systems: Is dedicated to providing organization-wide common systems for designing and measuring work processes; seeks to reduce variances in organization processes; delivers the highest quality products and services which meet the needs and requirements of internal and external customers; is committed to continuous improvement through empowerment and management by data; leverages technology to positively impact quality; is willing to re-engineer processes from scratch; is open to suggestions and experimentation; creates a learning environment leading to the most efficient and effective work processes.
Education & Experience
Bachelor’s degree in nursing. Masters’ degree in nursing or related field preferred. At least five years of clinical experience in an acute care setting. Familiar with TJC standards and 10NYCRR. Managerial experiencepreferred.