Job Description

The Director, Quality and Regulatory Affairs, is responsible for the oversight and direction of the Quality and Regulatory Affairs Department for one (or more, as assigned) hospital under the Mount Sinai Health System. This position involves the support of system, and hospital goals with a focus on quality/performance improvement and compliance with regulatory requirements.

• Coordinates the activities of the Quality and Regulatory Affairs Program including the design of program goals, plans, timelines, objectives and measurable/actionable performance metrics.
• Supports the coordination and direction of all activities to ensure the effective implementation of the Quality Assessment Performance Improvement and Patient Safety Plan.
• Assists in the development of goals and objectives to support alignment with the strategic initiatives of the hospital(s) and the system as well as compliance with Federal, State, City and Joint Commission requirements.
• Designs, develops, implements and evaluates quality improvement policies and procedures.
• Develops and facilitates the use of data collection tools to support data analysis.
• Coordinates and supports the quality committee structure.
• Oversees action plans to sustain and improve performance related to publically reported performance measures including core measures, eCQMs and pay for performance contractual obligations for both inpatient and outpatient settings.
• Directs the management and coordination of all on-site regulatory survey activity to include CMS, NYSDOH, The Joint Commission hospital triennial survey and Disease Specific Certification surveys. Directs the planning, preparation, scheduling and management of regulatory survey.
• Directs and coordinates the survey response corrective action plans and monitoring activities.
• Coordinates all documentation requirements for the Performance Improvement and National Performance Goal chapters of The Joint Commission manual.
• Assist in the coordination of a Failure Mode Effect Analysis at least every 18 months.
• Responsible for supporting the management of an operating budget for the department.
• Recommends capital expenditures as necessary.
• Interviews, hires, orients, and trains QRA staff.
• Assigns duties and monitors performance and productivity of staff.
• Completes annual performance appraisals.
• Serves as an internal consultant for quality improvement and regulatory compliance.
• Implements and supports high reliability principles in the design of quality improvement activities.
• Maintains current knowledge of quality improvement information, patient safety, and regulatory requirements.
• Maintains effective communication and working relationships with a wide variety of staff (hospital, medical, ambulatory, behavioral) to support and facilitate quality -related initiatives.
• Performs other related duties

Education Requirements ____________

Masters degree or greater required.

Experience Requirements __________________

5 years minimum in leadership position in health care quality improvement including at least 2 years of experience in managing staff. Knowledge of regulatory requirements. Strong communication and organizational skills. Knowledge of LEAN, High Reliability principles, Six-Sigma, and Change Management preferred.

Minimum Licensing and Certification Requirements

NYS RN, NP or P.A. or allied health professional licensure/certification/licensure preferred;

CPHQ preferred.

Strength through Unity and Inclusion

The Mount Sinai Health System is committed to fostering an environment where everyone can contribute to excellence. We share a common dedication to delivering outstanding patient care. When you join us, you become part of Mount Sinai’s unparalleled legacy of achievement, education, and innovation as we work together to transform healthcare. We encourage all team members to actively participate in creating a culture that ensures fair access to opportunities, promotes inclusive practices, and supports the success of every individual.

At Mount Sinai, our leaders are committed to fostering a workplace where all employees feel valued, respected, and empowered to grow. We strive to create an environment where collaboration, fairness, and continuous learning drive positive change, improving the well-being of our staff, patients, and organization. Our leaders are expected to challenge outdated practices, promote a culture of respect, and work toward meaningful improvements that enhance patient care and workplace experiences. We are dedicated to building a supportive and welcoming environment where everyone has the opportunity to thrive and advance professionally. Explore this opportunity and be part of the next 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 48,000 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 more than 9,000 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, top 5 in Cardiology/Heart Surgery, and top 20 in 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. 11 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.

Equal Opportunity Employer

The Mount Sinai Health System is an equal opportunity employer, complying with all applicable federal civil rights laws. We do not discriminate, exclude, or treat individuals differently based on race, color, national origin, age, religion, disability, sex, sexual orientation, gender, veteran status, or any other characteristic protected by law. We are deeply committed to fostering an environment where all faculty, staff, students, trainees, patients, visitors, and the communities we serve feel respected and supported. Our goal is to create a healthcare and learning institution that actively works to remove barriers, address challenges, and promote fairness in all aspects of our organization.