Associate Executive Director, Quality Management/Regulatory Affairs

NYC Health + Hospitals/ Harlem Published: November 1, 2017
Job Type


Come join the largest public hospital system in the nation! Every day, we work together to make an extraordinary difference in the health and well-being of each individual we serve – without exception. Join our team and help us create a positive patient experience.

NYC Health + Hospitals/Harlem is the largest hospital in Central Harlem, capable of treating the most seriously ill. The Hospital provides over 90 specialized ambulatory care services, including same-day surgery in our Aubrey S. Maynard Ambulatory Surgery Unit, behavioral health services, community substance abuse treatment, dentistry, and oral surgery.

NYC Health + Hospitals/Harlem is seeking an Associate Executive Director to oversee the Division of Quality Management/Regulatory Affairs, which is comprised of Infection Control, Risk Management, Medical Board, Credentialing, Regulatory, Patient Relations, Quality, Patient Safety, Utilization Management.
Some responsibilities include:

Ensuring that the facility remains survey-ready in the event of an unannounced site visit by regulatory agency representatives; prepare department/program staff for scheduled surveys conducted by regulatory agencies; prepare plans of corrections and monitor plans for improvement.

Implementing regulatory standards for all staff including management, clinical and support personnel.

Overseeing the coordination and review of Administrative and clinical Policies/ Procedures; developing and standardizing the Policies and Procedures for the facility.

Ensuring incidents are reviewed, investigated and reported to NYPORTS computerized system to facilitate incident report to the New York State Department of Health, Office of Health Systems Management.

Ensuring that all trended data is reported to the appropriate departments/committees; preparing and monitoring plans of correction for all identified citations.

Supervising the policy/procedure for sentinel events.

Overseeing chart reviewers who identify potential quality related issues.

Implementing FMEA (Failure Mode Effect Analysis) network wide.

Ensuring proper and timely completion of Root Cause Analysis and implementation of the improvement process.

Providing report of ongoing comparative analysis of information related to quality and environment of care.

Ensuring implementation of National Patient Safety Goals network wide and shares the monitoring data and ensure the implementation of Patient Safety Program hospital wide.

Minimum Qualifications
NY state licensed RN or MD
A Master’s Degree from an accredited college or university in the field of hospital administration, business administration, public health or health services management.
Ten (10) years or more of full-time quality management experience at a senior level of responsibility in hospital or health services administration, in urban academic medical centers providing large volumes of inpatient and outpatient services to underserved populations. Experience in working in multi-cultural, unionized settings.
Experience in public or voluntary organizations managing organizational change.
Extensive knowledge of hospital operations, performance improvement, regulatory requirements (ie Joint
Commission, CMS, DOH, NCQA, DOMH, etc.), applicable codes/standards, health care strategic planning; etc
Current or previous Joint Commission Survey experience preferred;
Ability to communicate effectively verbally and in writing QM plans, work plans, correspondence etc.;
Proficient in utilizing Microsoft Word, Excel, PeopleSoft, etc.
Ability to utilize LEAN thinking into improving processes and systems.

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