Job Abstract

Position Summary

Responsible to assess systems and processes across WPPA Practices, analyze, develop and implement system changes to enhance quality of care, organizational effectiveness and efficiency. This is a highly visible position with a broad range of responsibilities. The RN, Quality & Regulatory Readiness will work with appropriate leadership and subject-matter experts to assess practice-wide developmental needs and recognize performance improvement opportunities and workforce performance.

Essential Functions and Responsibilities Includes the Following:

1. Understands and adheres to the WPH Performance Standards, Policies and Behaviors.

2. Collaborates with the Director, Quality, and WPPA to monitor and maintain compliance with all regulatory, standards (i.e., State, Federal, and The Joint Commission on Accreditation of Healthcare Organizations) as they relate to Physician Practices.

3. Acts as a facilitator for regulatory readiness of the outpatient practices

4. Responsible for identifying, implementing, monitoring and evaluating clinical quality improvement (QI) activities and providing related consulting and support services.

5. Develops new programs to respond to changes in regulations, best practices, and to achieve the goals necessary to meet reimbursement/pay for performance criteria.

6. Leads and inspires staff toward changes that contribute to a culture of quality and safety throughout the Physician Practices.

7. Identifies annual quality/safety educational needs and facilitates such education

8. Fosters and maintains positive collaborative relationships with external agencies, and stakeholders related to quality /performance metrics.

9. Assists in the development, and conducting of risk assessments for Safety, Security and Infection Control and continually reviewing/analyzing the data and occurrences.

10. Keeps current with new regulations and develops strategies.

11. Develops and maintains all WPPA Policy & Procedures

12. Develops and participates in the onboarding process of newly acquired Physician Practices.

13. Foster relationships with new Physicians and staff.

14. Contributes at the monthly Practice manager/Administrators meetings

15. Serves as a resource and role model for all quality, operational and safety related activities.

16. Serves as a clinical and educational resource with regard to problem-solving through problem identification, action plan development and implementation and evaluation of outcome.

17. Prepares and provides statistical data related to areas of responsibility as needed (to internal departments and external agencies).

18. Performs all other related duties as assigned.

Education & Experience Requirements

• Professional Registered Nurse, licensed, currently registered by the State of New York

• BSN and or MSN required • Minimum 3 years’ experience in healthcare field

• BLS Required; Specialty certification preferred

• Experience in hospital and outpatient Quality and Regulatory Readiness

• Knowledge of e-learning, online policy systems and experience with learning management systems

• Strong proficiency with Microsoft Office products, MSWord, PowerPoint, Excel

Core Competencies

Clinical proficiency

Ability to multitask

Teamwork

Adaptability

Communication skills

Problem-solving skills

Planning and organizing

Attention to detail

Problem-solving skills

Judgment and decision-making

Stress tolerance

Project management

Physical/Mental Demands/Requirements & Work Environment

May be exposed to chemicals necessary to perform required tasks. Any hazardous chemicals the employee may be exposed to are listed in the hospital’s SDS (Safety Data Sheet) data base and may be accessed through the hospital’s Intranet site (Employee Tools/SDS Access). A copy of the SDS data base can also be found at the hospital switchboard, saved on a disc.

Walks, stands, sit throughout the day.

Manual dexterity for computer work, ability to focus and concentrate for report preparation and analysis of QI issues.

Must have a demonstrated ability to learn quickly, adapt to a variety of environments, and take responsibility and accountability for assigned projects is also required.

Must have a demonstrated ability to learn quickly, adapt to a variety of environments, and take responsibility and accountability for assigned projects is also required. Must be able to travel to and from multiple offsite locations on a daily basis

Primary Population Served

Check appropriate box(s) below:

☐Neonatal (birth – 28 days)

☐Patients with exceptional communication needs

☐Infant (29 days – less than 1 year)

☐Patients with developmental delays

☐Pediatric (1 – 12 years)

☐Patients at end of life

☐Adolescent (13 – 17 years)

☐Patients under isolation precautions

☐Adult (18 – 64 years)

☐Patients with cultural needs

☐Geriatric (> 65 years)

☐Bariatric Patients with weight related comorbidities

☐ Non-patient care population

☒All populations

The responsibilities and tasks outlined in this job description are not exhaustive and may change as determined by the needs of White Plains Hospital.