The Director, Quality and Regulatory Affairs, is responsible for the oversight and direction of the Quality and Regulatory Affairs Department for one (or more, as assigned) hospital under the Mount Sinai Health System. This position involves the support of system, and hospital goals with a focus on quality/performance improvement and compliance with regulatory requirements. 

 

Education Requirements                                                                                         ____________ 

Masters degree or greater required. 

 

 

Experience Requirements                                                                            __________________

5 years minimum in leadership position in health care quality improvement including at least 2 years of experience in managing staff. Knowledge of regulatory requirements. Strong communication and organizational skills. Knowledge of LEAN, High Reliability principles, Six-Sigma, and Change Management preferred. 

 

 

Minimum Licensing and Certification Requirements                                                                  

NYS RN, NP or P.A. or allied health professional licensure/certification/licensure preferred;

CPHQ  preferred.

• Coordinates the activities of the Quality and Regulatory Affairs Program including the design of program goals, plans, timelines, objectives and measurable/actionable performance metrics.

• Supports the coordination and direction of all activities to ensure the effective implementation of the Quality Assessment Performance Improvement and Patient Safety Plan.

• Assists in the development of goals and objectives to support alignment with the strategic initiatives of the hospital(s) and the system as well as compliance with Federal, State, City and Joint Commission requirements.

• Designs, develops, implements and evaluates quality improvement policies and procedures.

• Develops and facilitates the use of data collection tools to support data analysis.

• Coordinates and supports the quality committee structure.

• Oversees action plans to sustain and improve performance related to publically reported performance measures including core measures, eCQMs and pay for performance contractual obligations for both inpatient and outpatient settings. 

• Directs the management and coordination of all on-site regulatory survey activity to include CMS, NYSDOH, The Joint Commission hospital triennial survey and Disease Specific Certification surveys. Directs the planning, preparation, scheduling and management of regulatory survey.

• Directs and coordinates the survey response corrective action plans and monitoring activities. 

• Coordinates all documentation requirements for the Performance Improvement and National Performance Goal chapters of The Joint Commission manual.

• Assist in the coordination of a Failure Mode Effect Analysis at least every 18 months.

• Responsible for supporting the management of an operating budget for the department.

• Recommends capital expenditures as necessary.

• Interviews, hires, orients, and trains QRA staff.

• Assigns duties and monitors performance and productivity of staff. 

• Completes annual performance appraisals.

• Serves as an internal consultant for quality improvement and regulatory compliance.

• Implements and supports high reliability principles in the design of quality improvement activities.

• Maintains current knowledge of quality improvement information, patient safety, and regulatory requirements.

• Maintains effective communication and working relationships with a wide variety of staff (hospital, medical, ambulatory, behavioral) to support and facilitate quality -related initiatives.
• Performs other related duties