Clinical Process Improvement Administrator

Overview

At LiveOnNY we save lives, provide comfort, and strengthen legacies through organ, eye and tissue donation for the 13 million New Yorkers we serve.

This is an in-office role.

Under the guidance of the Director of CQAPI, ensures accurate and timely policy- and standards-compliant documentation, investigation, and corrective actions of Occurrences

within the Clinical and Recovery Services departments. Responsible for documentation of Clinical and Recovery Occurrence processes within LiveOnNY’s Quality Management

System and the performance of Clinical Review of identified Missed Referrals, to align with departmental and organizational strategic goals and Key Performance Indicators for

the purpose of improving organ / tissue donation and transplantation throughout LiveOnNY’s Donor Service Area.

Responsibilities

ESSENTIAL DUTIES AND RESPONSIBILITIES :

• Policy and Standards driven scheduling and coordination of Clinical Operations occurrence processes with appropriate organizational leadership,
• including occurrences identified in Clinical Services, Organ Allocation, Organ Recovery, Tissue Services, Donor Center, and Referral Triage.
• Conducts Investigations, Interviews, Root Cause Analyses, and Corrective Actions as indicated, in collaboration with the Director and Manager to
• ensure compliance with LiveOnNY policies, regulations, and standards.
• Responsible for Occurrence action items as follows :
• Reviews submitted Clinical and Recovery Services’ Occurrences for policy- and standards-appropriate throughput in LiveOnNY’s Quality Management System, includingreviewing assignments of categorization and severity level by the Process Transformation and Innovation Specialist, alongside identified key stakeholders.
• Identifies appropriate Occurrences for Root Cause Analysis. Organizes and conducts Root Cause Analysis processes, including identifying necessary involvement of departmental leadership and ensuring accurate and timely documentation and performance of investigations, corrective actions, and quality review prior to effectiveness assessments by the Department of Process Transformation and Innovation.

Ensures Occurrence Investigations, Interviews, and RCAs maintain focus on systemic, non-punitive perspectives amongst all participants and proposed actions.

• Ensures accurate and timely implementation and documentation of Clinical and Recovery Services’ Occurrence processes, from Occurrence Level review to preparation for Effectiveness Assessments.
• Ensures alignment of Occurrence documentation, process, and corrective action implementation with LiveOnNY policies, standards, and regulations.

Proactively identifies gaps and risk areas for the recommendation of Occurrence creation, integration, and / or revision.

• Advocates for accurate and timely identification and documentation of events as Occurrences in LiveOnNY’s Quality Management System as per policy.
• Collaborates with internal partners to troubleshoot and escalate barriers to RCA scheduling, performance, documentation, and assessment.

Proactively identifies barriers to Occurrence-driven corrective action identification or implementation.

Reviews and recommends policies and procedures to ensure compliance with Occurrence and RCA strategies and tactics to meet organizational goals.

Identifies need for new policy development / changes to meet regulatory requirements.

• Participates in Audits and Surveys as designated by departmental and organizational leadership to demonstrate and report out on Occurrences and their processes;
• collaborates with the Department of Process Transformation and Innovation to review and deliver Audit results into the Occurrence throughput as indicated;

reviews subsequent corrective actions and effectiveness assessments as appropriate for the development of Internal Audit schedules and contents.

• Conducts ad hoc audits of Clinical and Recovery Services as per request from interdepartmental leadership; proactively communicates ad hoc audit findings and interpretations with CQAPI and interdepartmental leadership.
• Collaborates proactively with the Department of Process Transformation and Innovation to establish policy-appropriate schedules and tasks for occurrence-driven Internal Audit development to improve processes and outcomes throughout Clinical Operations.
• Identifies impacted departments and key stakeholders for Occurrence and RCA reviews; participates in standardized data report-outs of findings, corrective actions, and effectiveness assessments in departmental and organizational meetings as directed.
• Responsible for Clinical Review of Missed Referrals from hospitals in LiveOnNY’s DSA as follows :
• Coordinates and receives identified Missed Referrals and associated medical records from Medical Record Reviewers for timely and accurate review each calendar month, to clinically confirm and document patients’ potential for Brain Death and DCD donation as per LiveOnNY policies, standards, and regulations.
• Coordinates and communicates appropriate Clinical Review schedules with Medical Record Reviewers to facilitate timely UNOS submission of Monthly Donation Data Reports by LiveOnNY’s Data Team.
• Ensures accurate and timely documentation of Clinical Reviews to facilitate targeted education of healthcare partners by LiveOnNY’s Hospital Services Specialists.

Connects rationale for Clinical Review with documented clinical data in a clear and comprehensive manner.

Provides expertise for, and elucidates, clinical determination of Brain Death and DCD potential per CMS definitions as documented in hospital medical records and electronic donor records.

Maintains up-to-date knowledge of Clinical Triggers as determined by policies, standards, and regulations.

• Proactively identifies existing or anticipated internal / external barriers and challenges to development, completion, or assessment of Clinical Review of Missed Referrals.
• Proactively escalates undetermined Eligibility and / or Potential of Missed Referrals to CQAPI and Clinical leadership for timely review.
• Participates in team huddles and organizational meetings, including meetings with organizational partners, regulatory agencies, and vendors as designated.
• Proactively identifies process improvement opportunities to departmental and organizational leadership, including recommendations driven by Occurrence and Clinical Review outcomes
• and organizational downstream impact.Other duties as assigned.

Qualifications

Clinical Process Improvement Coordinator Qualifications :

Required :

5 yrs clinical experience in an acute care hospital or ACLS setting OR 5 yrs experience as Transplant Coordinator performing active donor management at an OPO

1 yr experience in Performance / Process Improvement, Quality Assurance, or Regulatory in a healthcare setting

Preferred :

Degree in Healthcare Management, Healthcare Administration, or Informatics.

2 yrs experience conducting and documenting clinical data reviews in a healthcare setting.

2 yrs experience with Process Improvement methodologies such as Lean, Six Sigma, PDSA, RCAs, and / or A3 process mapping in a clinical / healthcare setting.

LiveOnNY offers a competitive salary & comprehensive benefits package.

• 403(b) deferred annuity
• Medical / Vision / Dental / Life
• Tuition reimbursement
• Paid time Off
• Pet Insurance
• Life Insurance
• Cellular plan discounts
• Auto Insurance discounts
30+ days ago