Director of Quality Management at NYC Health + Hospitals in Bronx, NY

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.

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.

Examples of Typical Tasks:

1. Directs the overall day-to-day operations of the Quality Management Department’s activities following evidencebased guidelines and regulatory requirements and is accountable for the operational excellence and quality delivery of service across the health care setting.

2. Designs, develops, and implements effective strategies and programs throughout the health care setting focused on improving quality, patient experience, and population health outcomes and reducing the cost of patient care.

3. Partners with key stakeholders to define the strategic direction for the Quality Management Department’s initiatives, ensuring alignment with the System’s mission, values, and business goals.

4. Monitors the effectiveness of the department’s activities and all quality management programs across the health care setting and facilitates successful evaluation of health care quality standards in line with governance provided by external regulatory agencies, as well as by other entities.

5. Coordinates the collection and analysis of all data related to quality indicators and utilizes findings to drive improvements, mitigate risks, and to increase the level of care within the System.

6. Recommends organizational objectives related to strategic plans and establishes service goals and identifies problems affecting the quality of service. Implements service and process improvement initiatives and other programs utilizing cost-effective solutions and service delivery enhancements.

7. Oversight of the 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.

8. Oversight of the Infection Prevention and Control activities: (1) meets regularly with the IC Team and the Infection Control Committee Chair to review IC Surveillance Reports for any gaps in IC Safe as well as the formulation of the yearly IC Plan, (3) provides guidance and assistance during an outbreak investigation and containment.

9. Oversight of the Hospital-wide Quality Assessment and Performance Improvement (HWAAPI) activities: (1) the development and finalization of the yearly Pl Plan, (2) the completion of the PI Annual Evaluation, (3) prepares the minutes, agenda and presentations for the (HWQAPI) committee meetings, (4) provides guidance and assistant to departments with their PI activities

10. Oversight of the Risk Management administrative activities: (1) provides guidance and assistance to the RM Team with the investigation of the Reviewable Sentinel Events to the Joint Commission, (2) provides guidance on the RM Report to HWQAPI, and (3) provides feedback on the RCA findings and corrective actions.

11. Performs other related duties as assigned by the Chief Executive Officer.

Minimum Qualifications:

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 care or 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.