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 planning, organizing, directing, and leading the personnel and work process of the Quality Management System. Scope of responsibility encompasses all settings of the organization. Has detailed understanding and can skillfully use the techniques of the system design, reengineering, project management, quality improvement, outcomes measurement, and analysis. Responsible for oversight of conformance to regulatory requirements, contractual obligations, and corporate policy by the organization's quality improvement program.
Assists the Director of Quality and Performance Improvement with identification of opportunities for improvement within the healthcare system. Evaluates requirements related to applicable accrediting and regulatory agencies and patient safety practices which improve outcomes. Coordinates activities that prepare the organization for regulatory accreditation. Formally conducts a gap analysis of operations as well as policies and procedures in collaboration with others as appropriate. Performs audits, tracers and record reviews as required. Creates materials regarding regulatory compliance and communicates information throughout the facility; works in collaboration with the Center for Education and the Public Relations Department. Provides consultative services for staff toward meeting standards of accreditation, performance improvement, and organizational compliance. Provides education to self and others on current accreditation standards, as well as the latest quality techniques in health care. Coordinates the implementation of the performance improvement program that meets the needs of patients, staff and external agencies. 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 three to five 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. 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.