Quality & Regulatory Excellence Director

Mount Sinai Medical Center; New York (NY); On-site; USD 140,000 - 210,000; Full time

Job summary

The Mount Sinai Health System seeks a Director, Quality and Regulatory Affairs to lead the Quality and Regulatory Affairs Department, aligning system and hospital goals with quality, performance improvement, and regulatory compliance.

Responsibilities include directing program goals, designing improvement policies, coordinating regulatory surveys, managing staff, budgeting, and acting as an internal consultant to advance high reliability and patient safety across inpatient and outpatient

Qualifications

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

Responsibilities

• Coordinates the activities of the Quality and Regulatory Affairs Program including goals, plans, timelines, objectives and performance metrics.
• Supports coordination and direction of all activities to ensure implementation of the Quality Assessment Performance Improvement and Patient Safety Plan.
• Assists in development of goals to support alignment with hospital/system initiatives and regulatory requirements.
• Designs, develops, implements and evaluates quality improvement policies and procedures.
• Develops data collection tools to support data analysis.
• Coordinates and supports the quality committee structure.
• Oversees action plans to sustain and improve public performance measures and contractual obligations.
• Directs management and coordination of all on-site regulatory survey activity (CMS, NYSDOH, Joint Commission).
• Directs survey response corrective action plans and monitoring activities.
• Coordinates documentation for Joint Commission and Performance Improvement/National Performance Goals.
• Assists in coordinating Failure Mode Effects Analysis at least every 18 months.
• Responsible for operating budget management and capital expenditures recommendations.
• Interviews, hires, orients, and trains QRA staff; assigns duties and monitors performance.
• Performs annual performance appraisals; internal consultant for quality improvement and regulatory compliance.
• Implements high reliability principles in quality improvement activities.
• Maintains knowledge of quality improvement, patient safety, and regulatory requirements.
• Maintains effective communication with hospital, medical, ambulatory, and behavioral staff.
• Performs other related duties.

Skills

Leadership

Quality improvement

Regulatory compliance

Education

Masters degree or greater

Tools

LEAN

Six-Sigma

Change Management

Job description

The Mount Sinai Health System seeks a Director, Quality and Regulatory Affairs to lead the Quality and Regulatory Affairs Department, aligning system and hospital goals with quality, performance improvement, and regulatory compliance.

Responsibilities include directing program goals, designing improvement policies, coordinating regulatory surveys, managing staff, budgeting, and acting as an internal consultant to advance high reliability and patient safety across inpatient and outpatient