Quality and Regulatory Affairs Specialist-BI - Mount Sinai Health System : Job Details

**JOB DESCRIPTION**

The Quality and Regulatory Specialist facilitates and participates in the implementation of the multidisciplinary hospital and system wide Clinical Quality and Patient Safety Performance Improvement Program. This is a healthcare professional who coordinates the planning, monitoring and evaluation of the Quality and Regulatory Readiness program. Participates in planned and unplanned regulatory visit activity. Promotes collaborative practice among departments/services for improved clinical outcomes, processes of care and regulatory compliance.

**RESPONSIBILITIES**

1. Facilitates the identification of opportunities for improvement and assist in the design and ongoing measurement of performance indicators and outcomes as part of the Clinical Quality and Patient Safety Performance Improvement Program.

2. Assists in planning, reviewing, and implementing activities related to the organizational goals and objectives including Quality and Safety Goals.

3. Collaborates with key stakeholders, peers and other departments to facilitate and monitor the timely completion of agreed upon corrective action plans arising from survey findings, root cause analyses or other sources.

4. Plans, coordinates and reports on a Failure Mode Effect Analysis.

5. Facilitate and participate in MSHS improvement initiatives as appropriate.

6. Supports an information system for quality and regulatory management data collection, data aggregation, and data analysis as well as the maintenance of an inventory of quality improvement activities including safety solution measures of success.

7. Monitors and displays statistical data for quality reports and evaluations.

8. Serves as internal resources for the quality and performance improvement process including data measurement, tool development, chart review, improvement strategies and education on improvement methodologies. Serve as a liaison with regulatory data abstraction and reporting.

9. Uses knowledge of standards of accreditation and regulatory agencies to assist with assessment of compliance. Conduct ongoing tracer rounds including observation, interview and medical record review to engage staff and assess compliance.

10. Participates in the preparation, planning, coordination and oversight of planned and unplanned regulatory survey and reporting by The Joint Commission, New York State Department of Health, CMS and other regulatory agencies as required.

11. Participates in the preparation, planning, coordination and oversight of disease specific certifications.

12. Develops and facilitates education workshops, meetings or conferences focused on improvement methodologies and regulatory compliance with high impact on program and/or participants; coordinates logistics, scheduling and participant communications.

13. Develops and writes communications and promotional literature for distribution such as newsletters, brochures or flyers; coordinates process from development through printing and distribution for quality and regulatory purposes.

14. Participates as a member of the hospital Quality Performance and Improvement Committee.

15. Supports and maintains the quality structure which includes all quality related committees including preparation of documentation and flow of material.

16. Supports the hospital Quality Performance and Improvement Committee, designated departmental committees, performance improvement taskforces and organizational improvement teams as appropriate.

17. Investigates and coordinates responses to quality of care inquiries arising from IPRO and other third party sources and patient complaints/grievances.

18. Interacts and maintains liaison with students, faculty, staff and outside/community agencies or committees in facilitating program objectives.

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

**QUALIFICATIONS**

Prior healthcare industry experience preferred, especially in the areas of quality or regulatory management, project management, and/or change management. CPHQ, Lean Six Sigma preferred

**ABOUT US**

**Strength Through Diversity**

The Mount Sinai Health System believes that diversity, equity, and inclusion are key drivers for excellence. We share a common devotion to delivering exceptional patient care. When you join us, you become a part of Mount Sinai's unrivaled record of achievement, education, and advancement as we revolutionize medicine together. We invite you to participate actively as a part of the Mount Sinai Health System team by:

+ Using a lens of equity in all aspects of patient care delivery, education, and research to promote policies and practices to allow opportunities for all to thrive and reach their potential.

+ Serving as a role model confronting racist, sexist, or other inappropriate actions by speaking up, challenging exclusionary organizational practices, and standing side-by-side in support of colleagues who experience discrimination.

+ Inspiring and fostering an environment of anti-racist behaviors among and between departments and co-workers.

At Mount Sinai, our leaders strive to learn, empower others, and embrace change to further advance equity and improve the well-being of staff, patients, and the organization. We expect our leaders to embrace anti-racism, create a collaborative and respectful environment, and constructively disrupt the status quo to improve the system and enhance care for our patients. We work hard to create an inclusive, welcoming and nurturing work environment where all feel they are valued, belong and are able to advance professionally.

Explore more about this opportunity and how you can help us write a new chapter in our history!

** About the Mount Sinai Health System:**

Mount Sinai Health System is one of the largest academic medical systems in the New York metro area, with more than 43,000 employees working across eight hospitals, more than 400 outpatient practices, more than 300 labs, a school of nursing, and a leading school of medicine and graduate education. Mount Sinai advances health for all people, everywhere, by taking on the most complex health care challenges of our time - discovering and applying new scientific learning and knowledge; developing safer, more effective treatments; educating the next generation of medical leaders and innovators; and supporting local communities by delivering high-quality care to all who need it. Through the integration of its hospitals, labs, and schools, Mount Sinai offers comprehensive health care solutions from birth through geriatrics, leveraging innovative approaches such as artificial intelligence and informatics while keeping patients' medical and emotional needs at the center of all treatment. The Health System includes approximately 7,400 primary and specialty care physicians; 13 joint-venture outpatient surgery centers throughout the five boroughs of New York City, Westchester, Long Island, and Florida; and more than 30 affiliated community health centers. We are consistently ranked by U.S. News & World Report's Best Hospitals, receiving high Honor Roll status, and are highly ranked: No. 1 in Geriatrics and top 20 in Cardiology/Heart Surgery, Diabetes/Endocrinology, Gastroenterology/GI Surgery, Neurology/Neurosurgery, Orthopedics, Pulmonology/Lung Surgery, Rehabilitation, and Urology. New York Eye and Ear Infirmary of Mount Sinai is ranked No. 12 in Ophthalmology. U.S. News & World Report's Best Children's Hospitals ranks Mount Sinai Kravis Children's Hospital among the country's best in several pediatric specialties. The Icahn School of Medicine at Mount Sinai is ranked No. 14 nationwide in National Institutes of Health funding and in the 99th percentile in research dollars per investigator according to the Association of American Medical Colleges. Newsweek's The World's Best Smart Hospitals ranks The Mount Sinai Hospital as No. 1 in New York and in the top five globally, and Mount Sinai Morningside in the top 20 globally.

The Mount Sinai Health System is an equal opportunity employer. We comply with applicable Federal civil rights laws and does not discriminate, exclude, or treat people differently on the basis of race, color, national origin, age, religion, disability, sex, sexual orientation, gender identity, or gender expression. We are passionately committed to addressing racism and its effects on our faculty, staff, students, trainees, patients, visitors, and the communities we serve. Our goal is for Mount Sinai to become an anti-racist health care and learning institution that intentionally addresses structural racism.

**EOE Minorities/Women/Disabled/Veterans**

**Requisition ID** : 3016671