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:

$134,000.00-$167,500.00

Title: Director, Quality and Safety

Department/Location:

Quality and Safety

Reports to:

Chief Medical Officer

Position Summary

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.

Essential Functions and Responsibilities Include the Following:

1. Understands and adheres to the MNR Performance Standards, Policies and Behaviors

2. Responsible for developing, coordinating and supervising a multi-disciplinary quality department.

3. Supervisory responsibilities including management of direct reports, oversight of the direct report’s work and completion of performance reviews for all direct reports.

4. 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).

5. 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.

6. Keeps abreast of Standards of Practice and policy through the literature; and makes appropriate

recommendations based on the literature.

7. Leads the development of quality and performance improvement programs including the submission, analysis, and synthesis of data and metrics.

8. Evaluates and supervises IDRs. RCAs and quality reviews.

9. Oversees and performs review of clinical quality of care issues through investigation, tracking, and initiation of provider interventions.

10. Coordinates the investigation of all the MIDAS RDE entries and collaborates with Risk Management on follow up actions when indicated.

11. Demonstrates appropriate utilization of resources necessary to obtain valid and reliable data entry.

12. 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.

13. Conducts orientation and in-service education programs about quality.

14. 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.

15. Attends Management/Leadership meetings as scheduled/required and communicates hospital policies, performance improvement initiatives and all other required information to staff.

16. Supports hospital initiatives and projects and functions as a positive change agent.

17. Promotes a positive and professional image and is a role model, coach, mentor and resource for staff and peers.

18. Performs all other related duties as assigned.

Education & Experience Requirements

• 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 employment (i.e. Surgical Clinical Reviewer – SCR, for NSQIP/MBSAQIP Program)

Core Competencies

• Ability to speak, write, understand, and communicate in English Language

• Perform multiple duties in a high-volume area

• Demonstrate analytical skills as well as accuracy and attention to details

• Ability to deal professionally and efficiently with all staff and all levels of management and external constituencies.

• Self-starter, self-motivated and ability to work without supervision

• Flexible, organized, and able to set priorities

• Excellent telephone manners and good communication skills

• Exhibit courteous, cooperative, and professional attitude at all times

• Retains composure under stress

Montefiore New Rochelle Hospital is an equal employment opportunity employer. Montefiore New Rochelle Hospital will recruit, hire, train, transfer, promote, layoff and discharge associates in all job classifications without regard to their race, color, religion, creed, national origin, alienage or citizenship status, age, gender, actual or presumed disability, history of disability, sexual orientation, gender identity, gender expression, genetic predisposition or carrier status, pregnancy, military status, marital status, or partnership status, or any other characteristic protected by law.