Director of Quality Management

Company: New York City Health and Hospitals Corporation
Location: New York
Posted on: May 18, 2025

Job Description:

Lincoln Medical and Mental Health Center is one of New York City's premier acute care hospitals. Located in Downtown Bronx, Lincoln is a teaching hospital renowned for its Centers of Excellence, and a recognized industry leader in the implementation of state-of-the art medical technology and best practices. Our team of highly trained and caring medical professionals is dedicated to providing the highest quality health care that is safe, compassionate, culturally competent and patient-centered. Comprehensive services are offered in three major primary care areas: Medicine, Pediatrics, and Women's Health in addition to more than eighty (80) specialty services. At Lincoln, the safety and comfort of our patients is our number one priority.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.Visit us at www.nyc.gov/html/hhc/lincoln.Job DescriptionPURPOSE OF POSITION: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.
DUTIES & RESPONSIBILITIES:
The Director of Quality Management/Director of Accreditation is charged with and responsible for the following:
1. Regulatory Affairs activities: (1) trains middle managers and senior leaders on how to conduct Tracer, as internal Mock Surveyors, (2) use of AMP Tracer Program, (3) prepares agenda and presentations for the Accreditation & Regulatory Compliance Committee (ARCC) meeting with primary focus on survey readiness, (4) manages all on-site regulatory visits, (5) coordinates all activities surrounding the application and on-site readiness for TJC Disease Specific Certifications, (6) coordinates the formulation of a comprehensive Plan of Correction (POC) with relevant staff/leaders, and (7) ensures the monitoring of POCs and providing compliance feedback to stakeholders.
2. Provides administrative oversight for the day-to-day operations of the Regulatory Affairs including staffing, training, performance expectations, Concurrent & Retrospective Clinical Chart Reviews; from the selection of indicators to the development of worksheets and the generation of reports, ongoing staff training on data abstraction, data analysis and PI concept
3. Provides support and guidance to the various departments during scheduled or unannounced regulatory surveys, coordinates plan of correction with the relevant team.
4. Ensures that the policies and procedures for departments are updated and aligned with current standards
5. Assists in Quality Management activities: Ensures timely data abstraction and submission of the mandated Core Measures for TJC and CMS, required indicators for ACO, Sepsis and Hospital Safety Scores for Leapfrog and the development and submission of the annual Institutional Plan.
6. Assists Chief Quality officer in coordination and submission of the quarterly report to the Quality Assurance Committee of H+H Board of Directors (QAC) of the H+H Board of Directors and the semi-annual and annual Governing Body Reports.
7. Assists Chief Quality Officer in the Hospital-wide Quality Assessment and Performance Improvement (HWQAPI activities: (1) the development and finalization of the yearly PI Plan, (2) the completion of the PI Annual Evaluation, (3) prepares the minutes, agenda and presentations for the HWQAPI Committee meeting, (4) provides guidance and assistance to departments with their PI activities.
8. Performs other related duties as assigned by the Chief Quality Officer.
Minimum QualificationsQualification Requirements:
1.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,
2.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,
3.Bachelor's degree in the disciplines as described in "1" above; and two (2) years of clinical, patient career 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, managerial or supervisory capacity; or
4.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.
How To ApplyIf you wish to apply for this position, please apply online by clicking the "Apply Now" button or forward your resume, noting the above Job ID #, to:NYC Health and Hospitals offers a competitive benefits package that includes:Comprehensive Health Benefits for employees hired to work 20+ hrs. per week
Retirement Savings and Pension Plans
Loan Forgiveness Programs for eligible employees
Paid Holidays and Vacation in accordance with employees' Collectively bargained contracts
College tuition discounts and professional development opportunities
Multiple employee discounts programs
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Keywords: New York City Health and Hospitals Corporation, North Bergen , Director of Quality Management, Executive , New York, New Jersey