Performance and Regulatory Strategist

Feb 22, 2021

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Job Description


To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values - integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day.

The Regulatory and Performance Strategist is responsible for participating in the regulatory readiness related to YNHH's ongoing advanced certification of The Joint Commission's Disease-Specific Care Comprehensive and Primary Stroke Center programs; and managing the delivery networks' system-related and outcome-related performance initiatives. The Regulatory and Performance Strategist ensures regulatory readiness compliance by collaborating with the stroke program's interdisciplinary team leadership in the development of evidence-based standards of care that are in keeping with the stroke program's mission and vision statements, and by overseeing the ongoing quality and safety healthcare performance improvement plans.



  • 1. Under the direction of the stroke program medical director and the stroke program manager, utilizes the resources required to maintain stroke program TJC certification with a focus on performance improvement initiatives 1.1 Assists the Stroke Program Manager and Stroke Coordinator with all tasks related to communications, applications, intra-cycle calls, on-site visits, and follow-up assignments related to regulatory readiness 1.2 Maintains a sound knowledge base on all certification for participation requirements, standards and elements of performance related to TJC certification, with a focus on Performance Management 1.3 Serves as a liaison for performance review and performance improvement for the stroke program across the YNHH HealthCare Network 1.4 When assigned, takes the lead in organizing he action plans related to the work of the Stroke Program's Peer Review Committee and ensuring that the follow-up practice and documentation are complete 1.5 Identifies and analyzes trends in satisfaction, quality outcomes and practice excellence using data systematically to guide change across system stroke practices.
    • 1.1 Assists the stroke program manager with all tasks related to communications, applications, intracycle calls, on-site visits, and follow-up assignments as it relates to the stroke program's regulatory readiness for both the York Street and St Raphael's campuses.
  • 2. Assist in setting priorities for the direction and tracking of all quality and safety practice for acute and recovery stroke care and for primary and secondary stroke prevention. 2.1 Responsible for the data aggregation and production of the monthly Brain Matters data summaries 2.2 Gathers aggregated data to substantiate initiatives to measure outcomes that impact overall patient health, and other benchmarks identified by the stroke program leadership 2.3 Develops expertise in using information systems and available technologies to improve stroke outcomes and to improve cost and efficiency 2.4 Shares the responsibility and accountability for effective high quality care and successful "stretch goals" with the stroke program leadership 2.5 Leads a multi-disciplinary team with the use of the applied change model (e.g. PDSA) to measure, facilitate improvement, and to report on the clinical and operational performance of stroke clinical care. 2.6 Utilizes an evidence-based research to establish the rationale for evolving a plan that will improve stroke care across the continuum 2.7 Shares the responsibility and accountability for effective high quality care and successful "stretch goals" with stroke program leadership
    • 2.1 Leads multi-disciplinary teams with the use of an applied change model (e.g. PDCA) to measure, facilitate improvement and to report on the clinical and operational performance of stroke clinical care.



Bachelor's degree required; advanced degree in a medical field and/or business degree preferred


Five years minimum experience in the healthcare field or business environment with focused experience in patient experience and performance improvement/safety and quality initiatives


not applicable


Background in neuroscience/stroke care and/or neuroscience rehabilitation preferred. Must be familiar with clinical process, organizational dynamics, and process improvement. Must be self-motivated, goal oriented and able to work independently. Must have the ability to develop relationships and work collaboratively and effectively in partnership with physicians, clinical staff, hospital departments and outside organizations. Must have excellent assessment, communication and organizational skills with the ability to mange and follow through on multiple priorities. Must have the ability and/or experience collaborating with senior leaders, physicians, nursing, and ancillary staff on business strategies and tactics. Must be able to translate research and data into clinical practice protocols. Must demonstrate excellent critical thinking, analysis and assessment skills for successful process improvement planning and monitoring. This position requires recognition as a leader demonstrating excellent interpersonal communication negotiation, problem solving, and customer service skills and ability to lead and motivate work teams. Project management, improvement tools and knowledge and application of change theories are required.

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Job Info

Job: 26661

Department: Stroke Program
Sub Category: ADMIN PROF
Status: Full Time Benefits Eligible
Shift: DAYS
Hours: 40

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