Specialist Regulatory Quality and Patient Safety- Hybrid- Brooklyn

NewYork-Presbyterian Hospital

8d•Hybrid

About The Position

As a Specialist Regulatory Quality and Patient Safety is a full-time person who will Participate in ambulatory continuous readiness activities to facilitate ongoing quality compliance with Joint Commission, CMS and DOH requirements. Serves as quality assurance subject matter expert for ambulatory teams. Collaborates with leadership, practice departments, service lines, operations and community settings on the implementation of standardized processes for quality, performance improvement, and regulatory activities across the NYP Ambulatory setting. Identifies opportunities for quality performance improvement, ensures implementation, and monitoring of any related data measurement and analysis. Lead multiple aspects of Ambulatory continuous quality improvement activities to facilitate ongoing compliance with Joint Commission, CMS and DOH requirements. Ongoing readiness activities include event review, RCA, tracing activity, ongoing focused standards assessment, training and education of quality improvement opportunities. Independently assess and respond to requests from practices. Guides clinical, quality, and operational leaders in solutions to address and improve quality concerns. Exercises judgement to determine what must be escalated. Synthesizes complex information for clinical, operational, and senior leaders. Identifies areas of risk. Reviews and interprets data and monitoring tools to ensure that standards are measured appropriately. Works with management to measure, interpret, and analyze data to ensure compliance, progress, and tracking towards corrective action plans. Maintains current knowledge of quality improvement, external standards and regulations, including but not limited to, the Joint Commission, CMS, and the DOH. Utilizing this knowledge serves as subject matter expert to assesses whether departmental policies, practices, and processes are in compliance with new and existing regulatory standards. Collaborates with ambulatory practices, service lines, outpatient clinics, and community-based care settings to implement standardized processes for accreditation, quality improvement, and regulatory activities. Interprets standards and identifies acceptable evidence of compliance in order to meet Joint Commission, CMS and DOH requirements. Serves as a liaison between practice leadership and other departments. Designs and delivers educational trainings to enhance the Ambulatory knowledge of quality best practice. Identifies and presents areas of regulatory risk to the organization including senior management. Reports results from mock surveys to department leadership. Participates in various hospital and Quality committees, work groups, or task forces as assigned, including enterprise-wide quality goals Project manage one or more quality goals annually. This position is a Hybrid schedule with hours 9:00am-5:00pm to support Brooklyn sites.

Requirements

Bachelor’s degree or equivalent experience
Minimum 5 years of experience, primarily in healthcare-related roles
Knowledge of Joint Commission, CMS and DOH requirements and/or experience with Joint Commission or regulatory survey activity
Experience with desktop computer applications and knowledge of database concepts.
Advanced skills with Microsoft applications including Outlook, Word, Excel, PowerPoint, and other web- based applications
Excellent communication skills, both oral and written
Experience with managing and interpreting data
Ability to manage multiple activities and meet timelines and deadlines
Ability to work with a variety of departments and levels of personnel
Clinical Licensure (RN, NP, PA, RD, PT/OT, or PharmD)
Experience in quality improvement environment

Nice To Haves

At least 3-5 years of healthcare or healthcare related experience
Master’s degree in a related field
Six-Sigma / Lean certification
Project Management Professional (PMP)
Experience in Quality and Patient Safety 3+ years
Project Management experience; ability to plan and lead project, facilitate project scope, develop project plans, manage timelines and provide direction and support to project team

Responsibilities

Participate in ambulatory continuous readiness activities to facilitate ongoing quality compliance with Joint Commission, CMS and DOH requirements.
Serves as quality assurance subject matter expert for ambulatory teams.
Collaborates with leadership, practice departments, service lines, operations and community settings on the implementation of standardized processes for quality, performance improvement, and regulatory activities across the NYP Ambulatory setting.
Identifies opportunities for quality performance improvement, ensures implementation, and monitoring of any related data measurement and analysis.
Lead multiple aspects of Ambulatory continuous quality improvement activities to facilitate ongoing compliance with Joint Commission, CMS and DOH requirements.
Ongoing readiness activities include event review, RCA, tracing activity, ongoing focused standards assessment, training and education of quality improvement opportunities.
Independently assess and respond to requests from practices.
Guides clinical, quality, and operational leaders in solutions to address and improve quality concerns.
Exercises judgement to determine what must be escalated.
Synthesizes complex information for clinical, operational, and senior leaders.
Identifies areas of risk.
Reviews and interprets data and monitoring tools to ensure that standards are measured appropriately.
Works with management to measure, interpret, and analyze data to ensure compliance, progress, and tracking towards corrective action plans.
Maintains current knowledge of quality improvement, external standards and regulations, including but not limited to, the Joint Commission, CMS, and the DOH.
Utilizing this knowledge serves as subject matter expert to assesses whether departmental policies, practices, and processes are in compliance with new and existing regulatory standards.
Collaborates with ambulatory practices, service lines, outpatient clinics, and community-based care settings to implement standardized processes for accreditation, quality improvement, and regulatory activities.
Interprets standards and identifies acceptable evidence of compliance in order to meet Joint Commission, CMS and DOH requirements.
Serves as a liaison between practice leadership and other departments.
Designs and delivers educational trainings to enhance the Ambulatory knowledge of quality best practice.
Identifies and presents areas of regulatory risk to the organization including senior management.
Reports results from mock surveys to department leadership.
Participates in various hospital and Quality committees, work groups, or task forces as assigned, including enterprise-wide quality goals
Project manage one or more quality goals annually.