ABOUT NYC HEALTH + HOSPITALS

Kings County Hospital Center has a rich legacy for its pioneering role in medicine. Today, with over 625 beds, our hospital remains on the cutting edge of technology and provides the most modern procedures with state-of-the-art equipment. Built in 1831 as a one room infirmary for publicly supported care of the sick, Kings County Hospital Center continues to be a leading healthcare facility whose mission is to provide care to everyone regardless of their ability to pay. The hospital provides a wide range of health services, and specialties are offered in all fields of modern medicine. More than 200 clinics provide a wide array of ambulatory care services.
At NYC Health + Hospitals, our mission is to deliver high quality care health services, without exception. Every employee takes a person-centered approach that exemplifies the ICARE values (Integrity, Compassion, Accountability, Respect, and Excellence) through empathic communication and partnerships between all persons.

MINIMUM QUALIFICATIONS

1. A Masters Degree or advanced clinical degree from an accredited college or university and two years of experience serving as a lead in soliciting, defining, and managing requirements for internally and externally developed software in a clinical, allied health, non-allied health, behavioral health, information technology, information services, business, analytics or related area; or, one year of experience in a relevant clinical and/or healthcare administration role/function; or
2. A Baccalaureate Degree from an accredited college or university and five years of experience as described above; or
3. A satisfactory combination of education, training, and experience.
4. Specialty certification(s) issued by a national commercially available program, state, professional society, academic or technical institution in an area(s) listed above, may be credited on a month-to-month basis toward the required work experience for a total of one year.

PURPOSE OF POSITION

Under the direction of the Chief of Surgery, works to improve the quality of care throughout the dept of Surgery. Collaborates with surgeons to plan, implement and evaluate surgical care through the use if the American College of Surgeons National Surgical Quality Improvement Program (NSQIP). Acts as the NSQIP Surgical Clinical Reviewer (SCR) to collect and analyze surgical quality and safety data using NSQIP online interface.

AREAS OF RESPONSIBILITIES

• Coordinates the Dept of Surgery QAPI program in collaboration with the Chief of Surgery.
• Coordinates Surgical QAPI meetings. Provides input into the agenda and reports significant trends, issues and outstanding items. Documents all minutes and assists in follow up of all issues
• Oversees the collection, tracking and benchmarking of surgical QAPI issues related to patient care.
• Correlates surgical QAPI outcomes and findings with NSQIP data for adherence to ACS criteria.
• Maintains NSQIP database to ensure adequate documentation as required by ACS.
• Produces and analyzes trended data and provider specific profiles.
• Assists in the preparation of any documentation and reports as requested by the Chief of Surgery or hospital administration.
• Attends mandatory NSQIP updates and external education programs as needed.
• Assists with preparation for site surveys.
• Assists with maintaining surgical policies and procedures.
• Identifies areas for improvement and education using QAPI data.
• Instructs others on pertinent standards and guidelines and ensures adherence to such.
• Performs all other related tasks as defined by the Chief of Surgery.
• Established effective working relationships with members of the hospital community, especially staff in the Surgery, Medicine, Nursing, Medical Records, Quality, and Information Systems Departments whose support is necessary for the management and success of the program.
• Contacts patients and/or families via telephone and/or written communications postoperatively for the purpose of identifying possible occurrences associated with surgical procedures performed at the hospital.
• Successfully completes the ACS NSQIP SCR Training/Certification Program

SUMMARY OF DUTIES AND RESPONSIBILITIES

Coordinates the Dept of Surgery QAPI program in collaboration with the Chief of Surgery. Acts as the
NSQIP Surgical Clinical Reviewer (SCR) to collect and analyze surgical quality and safety data using NSQIP online interface. Meets regularly with the Surgeon Champion and quality team to review results and make recommendations for QAPI actions.