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Munson Medical Center Stroke Program Manager-RN in Traverse City, Michigan

Find more information about our stroke program https://www.munsonhealthcare.org/stroke/stroke-services

SUMMARY

The Stroke Program Manager provides direction and oversight for the Primary Stroke Center Program and future Comprehensive Stroke Center Program. The primary responsibility of this position is to maintain all stroke-related certification/accreditations across the institution with the assistance of the stroke program staff.

The coordination activities of the Stroke Center include, but are not limited to: policy/procedure development and maintenance, continuing education program oversight for professional and community education, performance improvement process facilitation, and accountability for completeness and accuracy of publically reported data for certification and accreditation.

This position develops and manages the quality metric monitoring required to achieve and maintain certification which includes but is not limited to all data elements for certification by The Joint Commission or other regulatory bodies.

The program manager facilitates process improvement; coordinates improvement plans for the stroke program; interfaces with several different clinical departments; guides diverse groups to reach consensus; plans and facilitates meetings, communicates a clear vision of what constitutes program success.

ENTRY REQUIREMENTS

Currently licensed as a Registered Nurse in the State of Michigan.

Graduate of an accredited school of nursing, BSN required. MSN is preferred.

Stroke certification is required within the first year of employment. Current stroke certification is preferred.

Demonstrated experience with accreditation and certification standards of the Joint Commission or other accreditation agency.

The position requires strategic and conceptual-level analytic thinking and decision making skills, as well as an ability to manage under pressure, ambiguity, and change.

Demonstrated ability to lead/direct others and to work effectively with persons of varied background and educational experience. Effective at cultivating relationships necessary to address and resolve challenges.

Proven experience with, and knowledge of, current medical, interventional, and pharmaceutical treatment modalities of patients with stroke disease processes

Experience in analyzing and interpreting data to improve delivery of patient care.

Demonstrated experience in process improvement, new program development, budgeting, and/or clinical program proposals

Demonstrated ability to assess need for, design, implement, and increase performance for physician-driven metrics

ORGANIZATION

Directly reports to the Munson Medical Center Director of Critical Care with a dotted line report to the System Executive Director of Surgical Services for strategic system alignment.

Direct leadership and reporting authority is exercised over the stroke center quality coordinator and data abstraction staff members.

SPECIFIC DUTIES

  • Supports the Mission, Vision and Values of Munson Healthcare.

  • Embraces and supports the Continuance Improvement philosophy of Munson Healthcare with a focus on True North.

  • Promotes personal and patient safety.

  • Uses effective customer service/interpersonal skills at all times.

  • Coordinate and oversee all aspects of preparation for Joint Commission on-site surveys: Risk assessments, action plans, and presentations, physician credentialing & required CME, staff employee files & required CEU.

  • Oversee and monitor eligibility criteria compliance; partnering with the physician directors and marketing to ensure patient and procedure volumes are met as required by TJC.

  • Analyze effectiveness of current documentation and clinical workflows to identify opportunities for process and performance improvement using Lean methodologies to streamline processes and ensure the most efficient use of personnel and resources to meet The Joint Commission requirements.

  • Evaluate and monitor the impact of coded data on reimbursement, benchmarking, performance and outcome measure initiatives.

  • Community Outreach and Marketing: Collaborate with physicians and health educators to provide stroke education in the community; participate in regional programs and initiatives in relation to stroke care; works with marketing/communications to create awareness.

  • Develop and make presentations to institutional management and governance committees: Examples include but are not limited to preparing institutional quality committee presentations that discuss the strengths, challenges, objectives, goals, improvement efforts and guidelines of the Stroke Center

  • Manage and provide variance reporting of activity, commodity, and capital expenses.

  • Manage support staff/unit which conducts data abstraction duties to ensure that data abstraction happens within specified timeframes with exceptional accuracy to support patient safety and continuity of care. Work with clinical and technical stakeholders to ensure the abstraction process adds value and reduces waste.

  • Demonstrate consistent use of Lean methodology for problem analysis and improvement. Create and sustain visual metrics to track progress on key performance indicators in areas of responsibility.

  • Oversee and be accountable for the generation and dissemination of monthly/quarterly reports that: Demonstrate data over time (graphically displayed against benchmarks)

  • Identify outliers for clinical review and follow-up

  • Identify activities that effect outcomes

  • Anticipate potential areas of concern and initiate tracking procedures.

  • Participate in multidisciplinary process improvement initiatives focused on identifying root causes and correcting improper or ineffective processes, improving compliance and enhancing staff competency.

  • Independently lead and coordinate Joint Commission review for recertification as Stroke Center and intra-cycle phone review.

  • Responsible for maintaining cooperative working relationships with individuals representing other services in order to coordinate educational programs, patient transfers, provide referrals, and ensure provision of quality care and services.

  • Attend internal and external educational meetings and read professional resources in order to maintain and enhance nursing skills and clinical competencies. Keep current with new trends in stroke with the assistance of the medical directors.

  • Participate in the development of policies and procedures across service lines to reflect changing standards for stroke care that is evidence-based.

  • Participate in state wide Stroke Quality Improvement Programs

  • Performs other duties and responsibilities as assigned.

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