Director of Quality Management

Marketing Statement NYC Health + Hospitals/Jacobi is a 457-bed teaching hospital affiliated with the Albert Einstein College of Medicine. The facility has earned numerous Center of Excellence designations, accreditation, and recognition for its renowned Level 1 Trauma Center, Burn Center, Surgical Intensive Care Unit, regional Stroke Center, Snakebite Treatment Center, Breast Health Center, Bariatric Surgery Center, and Cancer Service. The facility also offers the region’s only multi-person hyperbaric chamber, allowing up to nine patients to dive together at one time. Jacobi’s Ambulatory Care Pavilion is a stunning complement to its inpatient acute care, allowing staff to provide patients with high-quality service in a modern, state-of-the-art environment. At NYC Health + Hospitals, our mission is to deliver high quality care health services, without exception. Every employee takes a person-centered approach that exemplifies the ICARE values (Integrity, Compassion, Accountability, Respect, and Excellence) through empathic communication and partnerships between all persons. Duties & Responsibilities The Director of Quality Management serves as an integral part of the multidisciplinary team overseeing the department’s activities across the health care setting directing and managing the daily operations of the department. The director formulates and institutes effective strategies and policies that focus on the delivery of quality, cost- effective health care services. Ensures optimal utilization of resources and compliance with the operating standards of various health care governing and accrediting bodies, resulting in an improved patient experience. Essential Duties And Responsibilities Directs the overall day-to-day operations of the Quality Management Department’s activities following evidence-based guidelines and regulatory requirements and is accountable for the operational excellence and quality delivery of service across the health care setting. Designs, develops, and implements effective strategies and programs throughout the health care setting focused on improving quality, patient experience, and population health outcomes and reducing the cost of patient care. Partners with key stakeholders to define the strategic direction for the Quality Management Department’s initiatives, ensuring alignment with the System’s mission, values, and business goals. Monitors the effectiveness of the department’s activities and all quality management programs across the health care setting and facilitates successful evaluation of health care quality standards in line with governance provided by external regulatory agencies, as well as by other entities. Coordinates the collection and analysis of all data related to quality indicators and utilizes findings to drive improvements, mitigate risks, and to increase the level of care within the System. Recommends organizational objectives related to strategic plans and establishes service goals and identifies problems affecting the quality of service. Implements service and process improvement initiatives and other programs utilizing cost-effective solutions and service delivery enhancements. Serves as both principal advisor and key resource to senior leadership, clinical staff, and other appropriate parties on matters pertaining to quality management techniques and systems, and presents findings of assessments, analyses, and safety incidents to various agencies, executives and/or senior managers. Advises on upcoming regulatory changes and required actions needed to meet or exceed new industry standards and to achieve improved outcomes. Deploys department resources in a strategic manner with the goal of achieving excellence in service delivery. Provides ongoing quality management training, guidance, and developmental opportunities to staff who impact the delivery of care. Routinely assesses staff learning needs and implements a competency assessment program to identify gaps and evaluates the quality and effectiveness of the programs. Implements necessary changes in trainings to maximize productivity, effectiveness, and efficiency of staff. Responsible for oversight of all processes necessary to meet regulatory standards from various governing bodies and accrediting agencies. Maintains readiness for unannounced agency visits and participates in various regulatory agency surveys. Serves as regulatory liaison, specifically as it relates to departmental performance and the creation of action plans to assist leadership in communicating newly adopted approaches in reaching medical excellence. Investigates incidents involving patient care and safety, and makes reports to the appropriate public health and regulatory agencies. Presents findings to related parties and incorporates new findings into affected procedural tools or programs. Makes recommendations relating to the prevention of such incidents and to determine quality control measures to foster a culture of safety for patients, staff, and visitors. Prepares and/or actively participates in the development of the quality management fiscal year budget and allocation of funds. Ensures operations run within budgetary guidelines, reviews budget requests for quality management initiatives, identifies and meets staffing needs to support the continuity of care. Performs other related duties, as directed. Minimum Qualifications Master’s degree from an accredited college or university in Quality Management, Hospital Administration, Health Care Administration, or in a related health care specialization; and five (5)years of experience in the development of organizational strategies and implementation of staffing plans, regulatory survey preparation and compliance, and in performance improvement and/or continuous quality improvement (CQI) initiatives in a hospital or health care setting, three (3) years of which must have been in a responsible administrative, managerial or supervisory capacity; or, Bachelor’s degree in the disciplines as described in "1" above; and seven (7) years of related experience, as listed in "1" above, five (5) years of which must have been in a responsible administrative, managerial or supervisory capacity; or, Bachelor’s degree in the disciplines as described in "1" above; and two (2) years of clinical, patient careor equivalent experience in a hospital or health care setting, plus three (3) years of related experience,as listed in "1" above, one (1) year of which must have been in a responsible administrative, managerialor supervisory capacity; or A satisfactory equivalent of education, training, and/or experience. Certified Professional in Healthcare Quality (CPHQ) may be substituted for one (1) year of experience, however, all incumbents must have at least a bachelor’s degree and one (1) year of responsible administrative, managerial or supervisory experience, as described in "1" above. #J-18808-Ljbffr