Nursing Quality & Regulatory Compliance Manager

About Us

At Sinai Chicago, we take health care personally. Excellence in health care is about more than just medicine, technology, tests and treatments, it is about really caring for people with dignity and respect. That’s what we do. We are dedicated to providing the best care to meet the needs of people, for our community, for our patients and for you.

The Nursing Quality and Regulatory Compliance Manager is responsible for enhancing the clinical quality and outcomes of Nursing practice using clinical data and project planning, implementation, and evaluation by applying evidenced-based best practices throughout Sinai Chicago. In addition, this role is responsible for developing systems and processes, which ensure continual Nursing survey readiness and regulatory compliance. The Nursing Quality and Regulatory Compliance Manager assesses, plans, organizes, directs, and evaluates overall Nursing quality and regulatory compliance initiatives at the unit, divisional, departmental and system level.

The role also collaborates with Nursing leadership, Nursing staff and other patient care related services, as well as those in Quality/Performance Improvement roles to enhance the quality of Nursing practice using clinical data and the application of evidence-based practice. The Nursing Quality and Regulatory Compliance Manager has the specific responsibility for providing leadership and direction in overall Nursing quality and regulatory compliance.

• Plans, coordinates, implements, and evaluates programs provided by Sinai Chicago relative to quality improvement and regulatory compliance
• Utilizes various assessments, tools, and data, identify gaps in compliance from a quality and regulatory compliance perspective in the Department of Nursing
• Provides oversight of the Nursing Quality data collection and submission to the Nursing Database of Nursing Quality Indicators (NDNQI) for benchmarking purposes and develop actions plans based on NDNQI reports and areas of opportunity
• Partner with Nursing Education to develop learning activities related to Nursing Quality improvement and regulatory standards
• Reports at the system, divisional and departmental level survey readiness findings, and action planning to ensure compliance
• Creates structure and processes to ensure optimal quality and compliant Nursing performance
• Partners with various service lines, departments, and leaders throughout the organization to promote and provide quality and compliance education that helps Sinai Chicago meet its mission and vision
• Serves as the Department of Nursing point of contact for surveyors during regulatory visits
• Collaborates with multidisciplinary professionals to integrate evidence-based interventions into a comprehensive plan of care to enhance patient outcomes
• Evaluates effects of system interventions for individuals and populations of patients/clients for clinical effectiveness, patient responses, efficiency, cost effectiveness, customer satisfaction and ethical considerations
• Identifies interpersonal, technological, environmental or system facilitators and barriers to the system implementation process
• Works collaboratively with interdisciplinary team to implement innovative evidence-based interventions that improve patient outcomes
• Represents Sinai Chicago on various advisory boards and commissions
• Mentors nursing and clinical staff at all levels of the organization to acquire new skills and develop their careers
• Works independently within the scope of nursing practice. The Executive Director for Nursing Professional Development will act as coach and mentor, provide direction, guidance, and feedback regarding practice and performance
• Performs other duties as assigned

• Bachelor of Science in Nursing (BSN) required
• Master s or higher-level degree in Nursing from an accredited school of Nursing preferred
• Five (5) years of clinical or leadership experience as a Registered Nurse
• Three (3) years of Nursing leadership experience
• Two (2) years of Nursing quality and/or regulatory compliance experience
• Knowledge of and experience working in Magnet recognized facilities
• Knowledge of…