Quality and Regulatory Affairs Specialist-Mount Sinai Brooklyn - Full-time

The Quality and Regulatory Specialist facilitates and participates in the implementation of the multidisciplinary hospital and system wide Clinical Quality and Patient Safety Performance Improvement Program. This is a healthcare professional who coordinates the planning, monitoring and evaluation of the Quality and Regulatory Readiness program. Participates in planned and unplanned regulatory visit activity. Promotes collaborative practice among departments/services for improved clinical outcomes, processes of care and regulatory compliance.

1. Facilitates the identification of opportunities for improvement and assist in the design and ongoing measurement of performance indicators and outcomes as part of the Clinical Quality and Patient Safety Performance Improvement Program.

2. Assists in planning, reviewing, and implementing activities related to the organizational goals and objectives including Quality and Safety Goals.

3. Collaborates with key stakeholders, peers and other departments to facilitate and monitor the timely completion of agreed upon corrective action plans arising from survey findings, root cause analyses or other sources.

4. Plans, coordinates and reports on a Failure Mode Effect Analysis.

5. Facilitate and participate in MSHS improvement initiatives as appropriate.

6. Supports an information system for quality and regulatory management data collection, data aggregation, and data analysis as well as the maintenance of an inventory of quality improvement activities including safety solution measures of success.

7. Monitors and displays statistical data for quality reports and evaluations.

8. Serves as internal resources for the quality and performance improvement process including data measurement, tool development, chart review, improvement strategies and education on improvement methodologies. Serve as a liaison with regulatory data abstraction and reporting.

9. Uses knowledge of standards of accreditation and regulatory agencies to assist with assessment of compliance. Conduct ongoing tracer rounds including observation, interview and medical record review to engage staff and assess compliance.

10. Participates in the preparation, planning, coordination and oversight of planned and unplanned regulatory survey and reporting by The Joint Commission, New York State Department of Health, CMS and other regulatory agencies as required.

11. Participates in the preparation, planning, coordination and oversight of disease specific certifications.

12. Develops and facilitates education workshops, meetings or conferences focused on improvement methodologies and regulatory compliance with high impact on program and/or participants; coordinates logistics, scheduling and participant communications.

13. Develops and writes communications and promotional literature for distribution such as newsletters, brochures or flyers; coordinates process from development through printing and distribution for quality and regulatory purposes.

14. Participates as a member of the hospital Quality Performance and Improvement Committee.

15. Supports and maintains the quality structure which includes all quality related committees including preparation of documentation and flow of material.

16. Supports the hospital Quality Performance and Improvement Committee, designated departmental committees, performance improvement taskforces and organizational improvement teams as appropriate.

17. Investigates and coordinates responses to quality of care inquiries arising from IPRO and other third party sources and patient complaints/grievances.

18. Interacts and maintains liaison with students, faculty, staff and outside/community agencies or committees in facilitating program objectives.

19. Maintains effective communication and working relationships with a wide variety of staff (hospital, medical, ambulatory, behavioral) to support and facilitate quality -related initiatives.

Prior healthcare industry experience preferred, especially in the areas of quality or regulatory management, project management, and/or change management. CPHQ, Lean Six Sigma 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