Director, Performance Improvement presso Stony Brook Southampton Hospital

POSITION SUMMARY: 

The Director of Quality and Performance Improvement assists and supports the Vice President of Quality Management in overseeing the Hospital’s Quality and Performance Improvement Program in all services and settings. Provides oversight to compliant management as an opportunity for improvement, performing concurrent and retrospective case reviews to facilitate and promote patient safety and quality outcomes. Oversees benchmarking study participation, outcome measurement, and identification of priorities for process improvement, serving as a facilitator to interdisciplinary continuous quality improvement teams.      

RESPONSIBILITIES:

• Assists in the development, coordination, and implementation of process improvement activities to measure the quality and efficiency of hospital wide initiatives, in all services and settings.

• Facilitates with multidisciplinary teams/departments to formulate Quality and Patient Safety initiatives, and PI Projects, based upon data trends and opportunities, via PDCA focus format, for improvement, outcomes, measurement and sustainability.

• Ensures patient and employee privacy.

• Attends and participates in Medical Staff committees where performance improvement activities are performed, as a nonvoting member.

• Serves as a mentor of continuous quality improvement, utilizing measure and QI tools, promoting quality improvement and safer patient outcomes.

• Assists the VP of Quality with the monitoring of hospital compliance with The Joint Commission readiness and New York State regulations and regulatory requirements, and Risk Management. 

• Assists with audits, chart reviews, investigations, deep dives and RCAs, NYPORT submissions, corrective actions and monitoring of compliance.

• Functions as a facilitative member of the Performance Improvement team performing integrated, concurrent reviews and care referrals consistent with the Performance Improvement Plan.

• Assists in assuring that Patient Rights and Patient Directives are central to care delivery, engagement and satisfaction.

• Actively participates in Hospital Wide Customer Service Experience.

• Collaborates with the Data Quality Manager in data analysis.

• Monitoring and tasking the organization’s occurrence reporting system, SB Safe, to ensure patient safety.

• Facilitates the SB Safe Oversight Committee to review open SB Safe’s greater than 45 days per policy, to collaborate on barriers identified and promoting resolution of events.

• Performs concurrent and retrospective case reviews and facilitates appropriate improvement actions are initiated and sustainable.

• Serves as liaison with Medical Staff and Quality Committee to identify areas of improvement.

• Serves as facilitator to interdisciplinary CQI teams, initiating, engaging and promoting initiatives to assure compliance and improve patient and staff satisfaction.

• Maintains appropriate documentation of all review’s activities, statistics, logs, reports, and data entry as appropriate.

• Supervises the Quality Coordinators daily activities, core measure extraction, electronic quality measures, incorporation analysis and implementation of necessary process improvement initiatives and validation of data as well as the timely submission of data elements/measure accordingly.

REQUIRED EXPERIENCE AND QUALIFICATIONS:

• Graduate of accredited School of Nursing.

• RN Current license in New York State.

• Bachelor’s Degree in Nursing.

• Minimum 5 years of current clinical hospital experience. 

• Ability to effectively interrelate with all members of the health care team.

• Effective verbal and written communication skills.

• Ability to analyze data and create statistical reports and tables.

• Knowledge of Joint Commission and New York State 405 requirements.

• Clinical expertise and evaluation skills, including extensive clinical nursing experience in an acute care hospital including specialty areas.

• Knowledge of legal aspects of health care.

PREFERRED EXPERIENCE AND QUALIFICATIONS:

• Masters degree in related field. 

• Experience in quality and performance improvement.

As part of employment at Southampton Hospital, there may be occasions when travel to other locations is needed to support operational needs.

Special Notes: Resume/CV should be included with the online application. 

• Stony Brook Medicine is a smoke free environment. Smoking is strictly prohibited anywhere on campus, including parking lots and outdoor areas on the premises.
• All Hospital positions may be subject to changes in pass days and shifts as necessary. 
• This position may require the wearing of respiratory protection, which may prohibit the wearing of facial hair. 
• This function/position maybe designated as “essential.” This means that when the Hospital is faced with an institutional emergency, employees in such positions may be required to remain at their work location or to report to work to protect, recover, and continue operations at Stony Brook Medicine, Stony Brook University Hospital and related facilities. 

Anticipated Pay Range:

The starting salary range (or hiring range) for this position has been established based on relevant experience.

The above salary range (or hiring range) represents SBSH’s good faith and reasonable estimate of the range of possible compensation at the time of posting.

Your total compensation goes beyond the number in your paycheck!

Prior to start date, the selected candidate must meet the following requirements: 

Successfully complete pre-employment physical examination and obtain medical clearance from Stony Brook Southampton Hospital’s Employee Health Services*

• Complete electronic reference check with a minimum of three (3) professional references.
• Successfully complete a 4 panel drug screen*
• Meet Regulatory Requirements for pre-employment screenings.

• Provide a copy of any required New York State license(s)/certificate(s).

   

Failure to comply with any of the above requirements could result in a delayed start date and/or revocation of the employment offer. 

*The hiring department will be responsible for any fee incurred for examination.

Company Overview:

Stony Brook Southampton Hospital as part of Stony Brook Medicine provides direct access to the highest level of academic-based medical care. Located in the heart of the village of Southampton, two hours from New York City, the hospital provides healthcare services to a diverse community of year-round residents, second homeowners and vacationers. The population, about 75,000 in the winter months, increases sharply to more than 300,000 in the summer. Stony Brook Southampton Hospital has been recognized as a Long Island Top Workplace by Newsday among large employers (defined as having 500+ employees). 

StaffCo is a Professional Employer Organization, commonly referred to as a PEO, duty organized and registered under the New York Professional Employer Organization Law. StaffCo and SUNY have entered into a professional employer agreement under which StaffCo is the employer of Stony Brook Southampton employees and responsible for employment, including, promotions, disciplines, terminations, the day-to-day direction and supervision of work, as well as labor relations and collective bargaining. StaffCo is fully responsible for providing all payroll and human resource services, including the payment of wages, collecting and reporting payroll taxes and maintaining any and all employee benefits.  SUNY Stony Brook Hospital is responsible for the operation of the hospital and provision of health care and is the co-employer as is necessary to conduct its responsibilities and for related licensure, regulatory or statutory requirements and obligations.    

Given StaffCo’s employment responsibilities, it is deemed the “employer” for employment and labor law purposes.  Thus, the employees are private sector employees of StaffCo, not public sector employees of SUNY.  The private sector nature of the StaffCo employees has been approved by NYS Civil Service and upheld in a decision by the US National Labor Relations Board.

Stony Brook Medicine is committed to excellence in diversity and the creation of an inclusive learning and working environment. All qualified applicants will receive consideration for employment without regard to race, color, national origin, religion, sex, pregnancy, familial status, sexual orientation, gender identity or expression, age, disability, genetic information, veteran status and all other protected classes under federal or state laws.

Stony Brook Southampton Hospital, consistent with our shared core values and our intent to achieve excellence, remains dedicated to supporting healthier and more resilient communities, both locally and globally.