About the Fireman Vascular Center
The Fireman Vascular Center is one of the only vascular centers in the country with specialists in every area of vascular disease. Clinicians from seven specialties diagnose and treat the full range of vascular conditions, create new treatments, and educate the next generation of medical leaders.
About the Department of Neurology
Guided by the needs of our patients, the mission of the Department of Neurology is to be the pre-eminent academic neurology department in the US (United States) by providing outstanding clinical care while rapidly discovering new treatments to reduce and eliminate the devastating impact of neurological disorders; training the very best neurologists, scientists, advanced practice providers and nurses of the future; and improving the health and well-being of the diverse communities we serve. Our core values are excellence in service, innovation, education, and neuroscience research in neurology.
Comprehensive Stroke Center (CSC) Quality and Compliance Nurse Manager
The Quality and Compliance Nurse Manager provides ongoing support to the Massachusetts General Hospital (MGH) Joint Commission certified Advanced Comprehensive Stroke Center (CSC) program. Under the direction of the MGH CSC Director and Associate Directors, the Quality and Compliance Nurse Manager provides overall program direction and coordination of the CSC, including quality assurance and maintaining Joint Commission certification Department of Public Health Designation and Get with the Guidelines Quality Award Status.
This role will include collaborating with a multi-disciplinary healthcare team to support successful Joint Commission re-certification every two years and complete a mid-cycle review between recertifications.
Ongoing activities will include educating the multi-disciplinary caregivers (including nurses, physicians, advanced care practitioners, pharmacists and therapists in various inpatient and ambulatory settings) about MGH stroke guidelines and protocols, and monitoring and ensuring their use across different role groups. The CSC Quality Manager will assist with providing general stroke education to hospital staff members , Emergency Medical Services, and Community Partners as required by the Joint Commission. The manager will , oversee the CSC data abstractors for stroke patient data collection and analysis, in-depth chart review of patients who have serious adverse events or protocol violations, updating existing stroke management guidelines, coordinating and participating in CSC meetings, collaborating with the stroke teams for new policy and procedure development and implementation, liaising with the Department of Public Health, the Coverdell, the Amercian Heart Association Get with the Guidelines-Stroke, and similar stroke-related regional or national programs, supporting the Mass General Brigham Network’s stroke quality improvement projects, and assisting with community stroke awareness initiatives.. The Quality and Compliance Nurse Manager will be a resource to nurses and other allied health personnel in the MGH CSC and to colleagues in our Telestroke program, including affiliated primary stroke center and acute stroke ready referral hospitals.
T he CSC Quality and Compliance Nurse Manager will support or participate in selected stroke clinical research projects. Success in this role will require collaboration among teams.
PRINCIPAL DUTIES AND RESPONSIBILITIES:
• Quality and Compliance Work
o Prepares institution for CSC application submissions and coordination of all site visits and intracycle calls; oversees preparation of all required documentation and supporting materials. The incumbent will work closely with colleagues in the Fireman Vascular Center, Neurology, and other departments to ensure compliance with Joint Commission requirements. In this capacity, they will help collect necessary data and documents that support our certification.
o Provides overall program direction and coordination of CSC program; directs all efforts towards continued CSC certification.
o Collaborates with Medical Director and other team members in the development of policies, procedures, protocols, guidelines and/or projects required for ongoing certification of the CSC program; ensures all assignments are completed
o Establishes annual program goals, in collaboration with the Medical Director; including development, implementation, and evaluation of QI (Quality Incentive) strategies to achieve annual goals
o Interviews, recruits, and hires direct reports. Participates in the interviewing and hiring decisions for other staff as appropriate and in collaboration with leadership.
o Conducts annual performance evaluations for direct reports and as appropriate and materially contributes to performance evaluations for other workforce in collaboration with leadership peers.
o Implements corrective action as needed in consultation with leadership and HR as indicated. Conducts clinical competency testing as needed.
o Maintains knowledge of and ensures compliance with all policies and regulatory requirements.
o Ensures all Joint Commission standards are met and ensures coordination with DPH (Department of Public Health), Core Measures and Meaningful Use and other hospital required reporting requirements related to stroke care.
o Oversees quality outcome measures; partners with team members in data collection, analysis, reporting and presentations.
o Works as liaison to PHS Stroke Quality efforts and EPIC tools and template developers to ensure high reliability systems are in place to support evidence-based care.
o Monitors progress against standards; identifies high risk issues and trends and implements interventions to achieve quality outcomes.
o Files safety reports as appropriate and participates in root cause analyses as needed. Encourages an environment of safety. Serves as a resource to colleagues within the CSC and to colleagues at affiliated primary stroke center and acute stroke ready referral hospitals.
o Serves as the CSC liaison to the hospital’s physicians, nurses, clinical and administrative team, and the community.
o Partners closely with multidisciplinary stroke team members to optimize patient outcomes and evidenced based practice.
o Participates in Data Review meeting monthly.
o Participates in Complex Care conference monthly (identifying cases in preparation)
o Identifies educational needs and provides comprehensive educational content and training for internal and external physicians, nurses, other allied health professionals and the community.
§ Works with the inpatient teams to ensure compliance with standard procedures and documentation requirements. Examples include use of the stroke navigator, timely assessment of swallow function, appropriate stroke preventive medications, documentation of stroke education using the after-visit summary (AVS).
o Provides Nursing Education to patients in the ED (Emergency Department)
§ Review quality measures
o Provides support Nursing education within the ambulatory stroke clinic.
• Stroke Research
o Collaborates with stroke team members on recruitment of subjects for research studies.
o Participates in writing of manuscripts and supports stroke research.
o Presents research findings at professional meetings as needed.SKILLS & COMPETENCIES REQUIRED:
• Excellent interpersonal and written and verbal communication skills
• Ability to work independently and as a member of a multidisciplinary team.
• Ability to take initiative and proactively identify problems and propose solutions
• High degree of professionalism, discretion, and confidentiality
• Experience coordinating programs and managing working relationships in a matrix organization
• Ability to manage multiple projects simultaneously, set priorities and provide updates
• Demonstrated ability to work directly with individuals at all levels of the organization
• Proven record of accomplishment of exercising good judgment and understanding of when to escalate issues
• Demonstrated knowledge of performance improvement methods, including statistical concepts and applications; understand how to analyze and present data
• Ability to work in a fast-paced, changing environment
• Demonstrated knowledge of working with regulatory agencies and adherence to compliance standards
• Familiarity with healthcare data analytical techniques
• Flexibility with the ever-changing healthcare landscape
• Ability to participate and support change management
LICENSES, CERTIFICATIONS, and/or REGISTRATIONS:
Licenses:
Required: Current licensure as a Registered Nurse in the Commonwealth of Massachusetts
Preferred:
• Additional training or expertise in stroke care
EDUCATION:
Master’s Degree Required
Preferred:
Field of Study/Additional Specialized Training: Certified Stroke Registered Nurse (SCRN) or Certified Neuroscience Registered Nurse (CNRN)
EXPERIENCE:
Required: Experience with quality improvement and regulatory requirements in a hospital setting
Preferred:
Greater than 5 years managing a Joint Commision Comprehensive Stroke Program
Greater than 7 years’ experience as a neuroscience nurse, preferably in an ICU setting
Previous leadership experience
Strong Computer literacy including Excel, PowerPoint, Redcap, Tableau
Strong command of data management, analysis and reporting
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