Summary:

The Stroke Coordinator plays a critical role in supporting the hospital's stroke program by ensuring ongoing compliance with American Heart Association (AHA) Get With The Guidelines (GWTG) and The Joint Commission (TJC) standards. This role is responsible for conducting thorough audits of stroke cases, entering and validating clinical data in the AHA GWTG/TJC stroke databases, and providing in-depth analysis of any care fallouts. The coordinator also leads targeted reviews such as Tenecteplase (TNK) case evaluations and manages EMS-related activities, including uploading prehospital data and auditing corrective action plans related to EMS survey results. Through detailed tracking, reporting, and interdepartmental collaboration, the Stroke Coordinator helps drive continuous quality improvement and stroke program excellence.

Essential Responsibilities:

Promotes learning in others by communicating information and providing advice to drive projects forward; builds relationships with cross-functional stakeholders. Listens, responds to, seeks, and addresses performance feedback; provides actionable feedback to others, including upward feedback to leadership and mentors junior team members. Practices self-leadership; creates and executes plans to capitalize on strengths and improve opportunity areas; influences team members within assigned team or unit. Adapts to competing demands and new responsibilities; adapts to and learns from change, challenges, and feedback. Models team collaboration within and across teams.

Conducts or oversees business-specific projects by applying deep expertise in subject area; promotes adherence to all procedures and policies. Partners internally and externally to make effective business decisions; determines and carries out processes and methodologies; solves complex problems; escalates high-priority issues or risks, as appropriate; monitors progress and results. Develops work plans to meet business priorities and deadlines; coordinates and delegates resources to accomplish organizational goals. Recognizes and capitalizes on improvement opportunities; evaluates recommendations made; influences the completion of project tasks by others.

Develops and implements data collection and analyses to support quality improvement efforts by: conducting advanced statistical analysis for quality improvement evaluations, special projects, and other work for multidisciplinary review; investigating opportunities to improve the reporting and narrative summaries of improvements by integrating multiple utilization data reporting systems to develop and maintain a variety of statistical reports in a format which enables care providers to see variations in practice patterns; presenting quality improvement metric reports to demonstrate improvements and effectiveness of quality improvement programs to department and program managers; and serving as a technical expert to team members, supervisor, and key stakeholders by interpreting trends, potential errors, and other analyses, by assisting in problem resolution for data source analysis, and by advising on the application of results.

Supports in-depth and advanced quality improvement and improvement risk management efforts by: researching corrective action plan for areas of improvement identified through utilization review, clinical records audit, claim denials, member satisfaction surveys, and auditing surveys for their cost effectiveness and impact on department functioning; ensuring process improvements are compliant with established internal and external regulation requirements at the local and state level; conducting complex root cause analysis, failure mode and effect analysis, and other assessments in response to significant events near

misses, and good catches in order to identify areas of improvement and evaluate newly internalized processes and programs; and proactively escalating high-risk issues and trends to appropriate entity for resolutions.

Investigates opportunities to develop new and improve current quality improvement performance metrics development, collection, and utilization by: researching and recommending best practices in the development of performance metrics, standards, and methods to establish improvement success; consulting with multiple stakeholders, often with competing/conflicting objectives, to ensure development of cohesive and reachable metrics are practical, meet multidisciplinary standards, and are approved at the department level; and designing the delivery of measurable results and alignment with strategic objectives by integrating metric utilization into workflows with sound methodology.

Facilitates the development of quality improvement initiatives by: leveraging and implementing advanced technology, methods, and tools to develop stakeholders capabilities for process improvements; monitoring the use of data-driven improvement principles, tools, and problem-solving methods, including Lean/Six-Sigma concepts and techniques using quality improvement metrics; and synthesizes key information and works to break down issues into logical part for the creation of milestones, detailed workplans, and documentation practices in order to create a clear, logical, and realistic plan.

Serves as the subject matter expert for quality improvement processes and regulations for internal and external stakeholders by: providing consultation independently on the interpretation and interaction of current policies, and how they interact with the current climate, and potential changes to regulations and legislation; serving as a technical advisor on committees, projects to drive discussions on drawing guidelines on the enforcement, development of policies or procedures of regulations and auditing processes; fostering collaborative, results oriented partnerships to ensure compliance with regulations and improve patient safety, maintain the KP safety culture, reporting accuracy, and health outcomes and provides insight to the regulation climate; developing educational programs to raise awareness for changes in regulation requirement, internal concerns, and system/database usage; and anticipating issues and weighs practical and technical considerations in addressing issues and coordinates with the appropriate stakeholders to develop resolutions.

Develops stakeholder development and quality performance review processes by: developing and improving the utilization and performance reviews processes by utilizing multidisciplinary criteria and guidelines, and takes a systematic approach to quality improvement; identifying performance areas of improvement for at the program, provides feedback and coaching as needed, and develops a corrective plan; presenting performance review reports at the program level to department managers; and developing the curriculum for training and educational programs related to process improvement for quality improvement programs.

Qualifications:

Minimum of recent (within 3 years) experience in a similar role required.

Minimum three (3) years of experience in a leadership role with or without direct reports required.

Minimum two (2) years of experience with databases and spreadsheets or continuous quality improvement (CQI) tools required.

Minimum four (4) years of experience in clinical setting, health care administration, or a directly related field required.

Bachelors degree in Business Administration, Health Care Administration, Nursing, Public Health, or related field AND Minimum six (6) years of experience in quality, performance improvement, or a directly related field OR Minimum nine (9) years of experience in quality, performance improvement, or a directly related field preferred.

Registered Nurse License (California).

Additional Requirements:

Knowledge, Skills, and Abilities (KSAs): Clinical Quality Expertise; Negotiation; Business Process Improvement; Risk Management; Compliance Management; Health Care Compliance; Applied Data Analysis; Consulting; Development Planning; Agile Methodologies; Project Management; Risk Assessment; Health Care Quality Standards; Quality Improvement.