Stroke Certification Coordinator-Clinical Compliance & Regulatory Sv - USA Health

USA Health is Transforming Medicine along the Gulf Coast to care for the unique needs of our community. 

USA Health is changing how medical care, education and research impact the health of people who live in Mobile and the surrounding area. Our team of doctors, advanced care providers, nurses, therapists and researchers provide the region's most advanced medicine at multiple facilities, campuses, clinics and classrooms. We offer patients convenient access to innovative treatments and advancements that improve the health and overall wellbeing of our community.

Collaborates with the Stroke Medical Director to review institutional activities related to the stroke care, guidelines, policies, and certification; coordinates and directs the Stroke Quality Improvement (Ql) plan and program; collaborates with medial staff, nursing, ancillary departments, and care management to ensure stroke patient care meets the standards; performs patient rounds with stroke team and participates in weekly stroke conference as needed; participates in local state and or national activities pertaining to stroke care; coordinates stroke activities to include stroke committee meetings, stroke support groups, data entry of stroke patient information. Stroke program accreditation, hospital staff education, patient education, community education and related activities; develops stroke patient treatment protocols based upon evidence-based practice guidelines; maintains knowledge competency in stroke care and Joint Commission certification; completes the Stroke Certification application and submits monitoring data; ensures survey readiness for the stroke certification site visit, and acts as a liaison for the stroke surveys; assists the Hospital Accreditation Coordinator with stroke certification/Joint Commission activities (eg Patient and data tracers); analyzes O1 data for trends and prepares reports for the stroke committee; facilitates resident education on stroke program PI measures with the American Heart Association. Get With the Guidelines (GWTG) program; organizes and reports Q1 data for use in the PI Program and in external and internal benchmarking programs according to the hospital’s Stroke PI Plan; abstracts and enters the Stroke Core Measures data into the GWTG web-based software program. Core Measure database and CMIP Joint Commission tool; validates the electronic clinical quality measures (eCQM) and meaningful use (MU) data for stroke patients; collaborates with the health services information system (HSIS) department in building or revising the electronic medical record, as needed; promotes of community -wide education regarding stroke and TIA; monitors the hospital's compliance with National Patient Safety Goals, as needed; provides orientation and annual education on stroke care; coordinates the tracking of required stroke education for all stroke care givers as required by the stroke statewide system; validates neurology resident and attending education for the NIHSS training upon hire and on a biannual basis; checks for new stroke admissions daily and rounds to ensure that stroke measures are being followed. Takes appropriate action to ensure meeting required indicators for GWTG and Joint Commission measures of quality care; conducts inter-rater reliability audits for the heart failure GWTG program; communicates and uses appropriate customer relation skills with physicians, patients, families and co-workers in person and via telephone; responds to pages, texts, and emails in a timely manner; utilizes group notification to communicate house wide that surveyors have arrived for survey; communicates with the Director/ Assistant Director regarding activities to meet continuous survey standards readiness; communicates recommendations for process improvements to Department Managers to meet standards and improve quality and safety of patient care; communicates the results and fall outs from monitoring results related to the stroke standards compliance to managers; maintains accurate, complete, & confidential information utilized in the hospital Performance Improvement program; maintains documentation book for the unannounced stroke site visit; prepares action plans and responses related to recommendations for improvement related to survey findings for submission to The Joint commission; prepares reports related to survey tracer findings, mock survey outcomes joint commission monitoring requirements; RCA's and Intra-cycle monitoring; accepting and completing all duties positively and without conflict; helping others and improving the performance of the QM department; completing all mandatory department. educational and hospital requirements; utilizing cost effective practices in performing all aspects of the job; adheres to current Infection Control and Safety standards; plans collects, organizes and reports QA data for use in the PI program and in external and internal benchmarking programs according to the hospital's PI Plan; liaison with Risk Management, and Patient Safety Officer in relaying potential risk issues as indicated; maintains current knowledge of the Joint Commission (TJC) CMS standards for stroke certification survey; serves as a member of various committees as directed; advises department heads in quality care planning. monitoring, education, and evaluation activities; uses internet, e-mail databases spreadsheets. word processing and presentation programs; provides education regarding Joint Commission and Performance Improvement activities to healthcare staff audiences; develops tools to assist in performance measurement and assists the organization in identifying improvement opportunities; abide by and enforce all compliance requirements and policies and performs these responsibilities in an ethical manner consistent with the organization's values; adheres to policies pertaining to confidentiality; regular and prompt attendance; ability to work the assigned overtime including overtime and call as required; requires minimal supervision to provide support for PI program; regular and prompt attendance; ability to work schedule as defined and overtime as required; related duties as required.

Bachelor's degree in nursing or allied health or a related field from an accredited institution as approved by the University of South Alabama. Four years of related experience and current licensure in clinical field. A Master's degree is preferred and may substitute for up to one year of the required experience. Experience in a stroke center is preferred. Hospital performance improvement experience, healthcare research or data collection analysis presentation is preferred