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Comprehensive Stroke Quality Nurse Manager - (3070775)






About the Fireman Vascular Center

The Fireman Vascular Center is one of the only vascular centers in the country with specialists in every area of vascular disease. Clinicians from seven specialties diagnose and treat the full range of vascular conditions, create new treatments and educate the next generation of medical leaders.

About the Department of Neurology


Guided by the needs of our patients, the mission of the Department of Neurology is to be the pre-eminent academic neurology department in the US by providing outstanding clinical care while rapidly discovering new treatments to reduce and eliminate the devastating impact of neurological disorders; training the very best neurologists and scientists of the future; and improving the health and well-being of the diverse communities we serve.  Our core values are excellence in service, innovation, education, and neuroscience research in the field of neurology.


Comprehensive Stroke Center Quality and Compliance Nurse Manager

The Quality and Compliance Nurse Manager manages the ongoing support of the Joint Commission Comprehensive Stroke Center (CSC) program.  The initial phases of this role will include recruiting and motivating a team to support successful re-certification.  Re-certification entails data collection and analysis, chart review, guideline, policy and procedure development and implementation, and coordinating an onsite visit by the Joint Commission.  Some team members will be direct reports, but success will also require collaboration across teams.  The Quality and Compliance Nurse Manager provides overall program direction and coordination of the Comprehensive Stroke Center program, quality metrics and certification. The Quality and Compliance Nurse Manager ensures compliance with all policies and regulatory requirements, maintains protocol documents and data reporting required for ongoing certification, ensures coordination with the DPH, Core Measures and Meaningful Use reporting requirements, provides educational content and training to other individuals in the CSC, is a resource to nurses and other allied health personnel in the CSC and to colleagues at affiliated primary stroke center and acute stroke ready referral hospitals. 












  • Prepares institution for CSC application submissions and coordination of all site visits and intracycle calls; oversees preparation of all required documentation and supporting materials. The incumbent will work closely with colleagues in the Fireman Vascular Center, Neurology, and other departments to ensure compliance with Joint Commission requirements.   In this capacity, they will help collect necessary data and documents that support our certification.

  • Provides overall program direction and coordination of CSC program; directs all efforts towards continued CSC certification

  • Collaborates with Medical Director and other team members in the development of policies, procedures, protocols, guidelines and/or projects required for ongoing certification of the CSC program; ensures all assignments are completed

  • Establishes annual program goals, in collaboration with the Medical Director; including development, implementation, and evaluation of QI strategies to achieve annual goals

  • Interviews, recruits and hires direct reports. Participates in the interviewing and hiring decisions for other staff as appropriate and in collaboration with leadership. Conducts annual performance evaluations for direct reports and as appropriate and materially contributes to performance evaluations for other workforce in collaboration with leadership peers. Implements corrective action as needed in consultation with leadership and HR as indicated. Conducts clinical competency testing as needed.

  • Maintains knowledge of and ensures compliance with all policies and regulatory requirements

  • Ensures all Joint Commission standards are met and ensures coordination with DPH, Core Measures and Meaningful Use and other hospital required reporting requirements related to stroke care

  • Oversees quality outcome measures; partners with team members in data collection, analysis, reporting and presentations

  • Works as liaison to PHS Stroke Quality efforts and EPIC tools and template developers to ensure high reliability systems are in place to support evidence-based care

  • Monitors progress against standards; identifies high risk issues and trends and implements interventions to achieve quality outcomes.  Files safety reports as appropriate and participates in root cause analyses as needed.  Encourages an environment of safety. Serves as a resource to colleagues within the CSC and to colleagues at affiliated primary stroke center and acute stroke ready referral hospitals

  • Serves as the CSC liaison to the hospital’s physicians, nurses, clinical and administrative team, and the community

  • Partners closely with multidisciplinary stroke team members to optimize patient outcomes and evidenced based practice

  • Identifies educational needs and provides comprehensive educational content and training for internal and external physicians, nurses, other allied health professionals and the community






  • Excellent interpersonal and written and verbal communication skills

  • Ability to work independently, as well as, as a member of a multidisciplinary team.

  • Ability to take initiative and proactively identify problems and propose solutions

  • High degree of professionalism, discretion, and confidentiality

  • Experience coordinating programs and managing working relationships in a matrix organization

  • Ability to manage multiple projects simultaneously, set priorities and provide updates

  • Demonstrated ability to work directly with individuals at all levels of the organization

  • Proven track record of exercising good judgment and understanding of when to escalate issues

  • Demonstrated knowledge of performance improvement methods, including statistical concepts and applications; understand how to analyze and present data

  • Ability to work in a fast-paced, changing environment

  • Demonstrated knowledge of working with regulatory agencies

  • Familiarity with healthcare data analytical techniques



Required: 1-2 years of direct care nursing experience on a stroke unit or in a data abstraction and quality role


Preferred: Previous leadership experience in stroke/neurology care and one to two years of experience in a nursing management role or experience working with regulatory agencies strongly preferred.






Required: Current licensure as a Registered Nurse in the Commonwealth of Massachusetts

Preferred: Advanced Practice Provider such as Clinical Nurse Specialist or Nurse Practitioner




Bacherlor's degree required.

Master's degree preferred.




Primary Location

: MA-Boston-MGH Main Campus

Work Locations


MGH Main Campus 

55 Fruit Street 

 Boston 02114



: Nursing


: Massachusetts General Hospital(MGH)


: Full-time

Standard Hours: 40


: Day Job

Employee Status

: Regular

Recruiting Department: MGH Neurology

Job Posting

: Aug 28, 2018

Comprehensive Stroke Quality Nurse Manager - (3070775)

Boston, MA
Full Time

Published on 10/08/2018