St. Joseph’s Healthcare System is recognized for the expertise and compassion of its highly skilled and responsive staff. The combined efforts of the organization’s outstanding physicians, superb nurses, and dedicated clinical and professional staff have made us one of the most highly respected healthcare organizations in the state, the largest employer in Passaic County, and one of the nation’s “100 Best Places to Work in Health Care”.
Responsible for coordinating performance improvement activities for the major service lines and departments. Provides guidance, facilitates, and works cooperatively with physicians/clinicians, administration, allied health, and supports staff involved in the quality and performance improvement process. This includes and not limited to the identification, development, implementation, and assessment of clinical, quality, and patient safety and compliance with accreditation and regulatory agencies.
Coordinates the development, implementation, measurement, analysis, and improvement processes needed to continually improve the effectiveness of the Quality Management System. Provides support to service lines and major departments in compiling both processes and outcomes data for quality as linked to the strategic plan for the Service Line/Department. Assists the organization in maintaining ongoing compliance with regulatory agencies. Responsible for timely abstraction and submission of designated Hospital Inpatient Quality Reporting Program measures. Seeks out external sources of competitive benchmark data through a variety of mechanisms against which to compare quality indicators. Facilitates teams to conduct root cause analyses and failure mode and effect analysis. Develops, and teaches use of PI tools for PI teams, planning initiatives, and development and implementation of focused studies and practice guidelines. Leads and assists in investigation of quality referrals and clinical outcomes. Identifies, screens, prepares, coordinates, and documents quality referrals, and clinical peer review activities. Serves as a resource to the organization and Medical Staff for quality of clinical care processes and outcomes. Serves as a resource to the organization and Medical Staff in the monitoring and evaluation of the quality of patient care provided. Performs trend analysis and identifies quality improvement opportunities. Meets all required competencies for department, unit and/or hospital. Responsible for performing all other duties as assigned. Special Projects
Work requires the knowledge of theories, principles, and concepts normally acquired through completion of a Bachelor's degree in Nursing or closely related field, and two to three years of work related experience. Master's preferred in Nursing, Health Care Administration or closely related field. Licensure required as a Registered Nurse by the State of New Jersey. CPHQ certification preferred. Work requires the knowledge of federal and state regulations, standards, and practices for an acute care hospital. Work requires the analytic ability necessary to resolve problem requiring a professional level of knowledge in specific discipline/field and to design complex educational, clinical, data processing systems and programs.