ABOUT NYC HEALTH + HOSPITALS

NYC Health + Hospitals/Metropolitan is the community hospital of choice for residents of East Harlem, northern Manhattan, and neighboring communities. The hospital provides culturally-sensitive care in a welcoming and hospitable setting, emphasizing primary care medicine and utilizing the latest advances in medical science. Metropolitan delivers high quality health services with compassion, dignity, and respect to all, without exception. Since its founding in 1875, the hospital has been affiliated with New York Medical College, representing the oldest partnership between a hospital and a private medical school in the United States. Metropolitan is a part of the NYC Health + Hospitals, the largest municipal hospital and health care system in the country.
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.

MINIMUM QUALIFICATIONS

1. Licensed and currently registered to practice as a professional nurse in New York State, plus (2) or (3), below.
2. Masters Degree in Nursing Administration, Education, Clinical Specialty or equivalent field and five years of satisfactory nursing experience, of which three years shall have been in a supervisory or teaching capacity; or a Baccalaureate Degree in Nursing and six years of satisfactory nursing experience, four years of which shall have been in a supervisory or teaching capacity.
3. A satisfactory equivalent of education and experience. However, all candidates must be licensed and currently registered to practice as a Professional Nurse in New York State.

PURPOSE OF POSITION:

Under general supervision of the Associate Director of Nursing, assists with the planning, organizing, directing, coordinating and evaluating of nursing service and education programs of the hospital, diagnostic and treatment center, or a major unit within the Department of Nursing. Performs related work.

RESPONSIBILITIES:

• Participate in survey preparedness and readiness activities (e.g., environmental rounding, tracer activity, mock surveys, education, monitoring) in preparation for regulatory and accreditation surveys, e.g., NYC DOHMH, NYS OMH, NYS DOH Article 28, Title 18, Behavioral Health and other announced and unannounced surveys/investigations.
• Collect, analyze and prepare data (e.g., key metrics and performance indicators, deficiencies/citations) for presentations and reports.
• Develop standard tracking and monitoring tools and databases such as ongoing schedule of regulatory surveys (past and upcoming), survey findings, key departmental owners/stakeholders, policies and procedures, regulatory agencies and key contacts.
• Facilitate and prepare documents for department meetings, including but not limited to scheduling, preparation of agendas, minutes, attendance, meeting materials, tracking issues and follow-up items.
• Work with Director and clinical and administrative stakeholders to develop, maintain, and update policies and procedures
• Maintain online library of policies and procedures
• Facilitate/ coordinate approval of policies and procedures
• Assist departments/programs to ensure ongoing compliance with applicable laws, rules, and regulations for ongoing survey readiness as well as for upcoming surveys.
• Assist in preparation, instruction and review of plans of correction
• Monitor plans of correction from external surveys as well as internal reviews
• Continuously review regulatory/accreditation agencies websites for revisions and updates to standards, rules, and regulations
• Conduct education on creating compliance monitoring tools, preparing plans of correction, and preparing for regulatory surveys
• Establish standardized, ongoing monitoring and tracking process for vendor agreements.
• Provide support to/serve as back up for the Designated Facility Research Coordinator for Metropolitan
• Ensure that research activities comply with NYC Health + Hospitals and Metropolitan policies and procedures as well as with external regulations, e.g. human subjects’ protections, conflicts of interest, Institutional Review Board (IRB)
• Review and approve research protocols (administratively) and provide feedback to research teams to ensure required elements and forms are submitted
• Run reports from the System for Tracking and Approving Research (STAR)
• Provide support to/serve as back up for Office of Student Affairs as needed:
• Assist in development and execution of clinical student agreements
• Oversee maintenance of department databases (e.g., students, schools, programs, key contacts, fees, and rotation calendars)
• Ensure student compliance with workforce requirements, e.g., mandated training and education (HIPAA, Annual In-Service, etc.)
• Assist in overall operations of the Regulatory Affairs Department, including special projects and other duties as assigned.