Director of Quality And Reg Affairs

City/State:
New Rochelle, New York
Grant Funded:
No
Department: MNR Financial Operations

Work Shift:

Day
Work Days: MON-FRI
Scheduled

Hours:

8:30 AM-5 PM
Scheduled Daily

Hours:

7.5 HOURS
Pay Range: $-$

Director, Quality and Safety Department/

Location:

Quality and Safety

Reports to:

Chief Medical Officer

The Director of the Quality Department manages the overall operations of the department and the development, coordination and supervision of the multifaceted, multidisciplinary quality department. The Director of Quality leads the successful maintenance and implementation of quality improvement programs and regulatory programs for the organization.

• Understands and adheres to the MNR Performance Standards, Policies and Behaviors
• Responsible for developing, coordinating and supervising a multi-disciplinary quality department.
• Supervisory responsibilities including management of direct reports, oversight of the direct report’s work and completion of performance reviews for all direct reports.
• Assures staff accurately abstract Quality Measures from medical records for internal and external measure sets (CMS, TJC, GWTG, Sepsis, NSQIP, MBSAQIP, and any additional quality programs).
• Keeps abreast of all pertinent federal and state regulations, NYS DOH laws and MNR policies as they presently exist and as they are changed or modified.
• Keeps abreast of Standards of Practice and policy through the literature; and makes appropriate recommendations based on the literature.
• Leads the development of quality and performance improvement programs including the submission, analysis, and synthesis of data and metrics.
• Evaluates and supervises IDRs. RCAs and quality reviews.
• Oversees and performs review of clinical quality of care issues through investigation, tracking, and initiation of provider interventions.
• Coordinates the investigation of all the MIDAS RDE entries and collaborates with Risk Management on follow up actions when indicated.
• Demonstrates appropriate utilization of resources necessary to obtain valid and reliable data entry.
• Acts as a liaison between the Department and all hospital departments including, but not limited to medical services, administration, nursing services and all other direct and indirect patient care services.
• Conducts orientation and in-service education programs about quality.
• Responsible and accountable for the quality department including development of department goals and objectives that are consistent with the hospital mission, the management of personnel, preparing/monitoring of and accountability for the department budget.
• Attends Management/Leadership meetings as scheduled/required and communicates hospital policies, performance improvement initiatives and all other required information to staff.
• Supports hospital initiatives and projects and functions as a positive change agent.
• Promotes a positive and professional image and is a role model, coach, mentor and resource for staff and peers.
• Performs all other related duties as assigned.

• Bachelor’s degree in related healthcare field required. If an RN must have a BSN. Master’s Degree preferred.
• 3-5 years in a leadership role along with clinical experience in one of the following: nursing, physician assistant, physical therapy, respiratory therapy.
• Receive CPHQ Certificate (Certified Professional in Healthcare Quality) from the National Association for Healthcare Quality (NAHQ) within 3 years after being in the position
• LEAN or Six Sigma education/certification preferred.
• -Knowledge of Microsoft Office Suite preferred (Word, Excel, PowerPoint, Outlook)
• If applicable the ability to obtain necessary license and certifications as needed within 3 months of…