JOB SUMMARY

The Senior Director of Quality Management Systems and Regulatory Affairs is responsible for establishing and promoting quality outcome standards towards safety, effectiveness and efficiency enterprise-wide. Provides leadership for advancing, developing, refining and innovating quality and regulatory operations throughout the organization.
The Senior Director of Quality Management Systems & Regulatory Affairs is accountable for developing, leading, and executing large scale quality support projects around day to day organizational performance throughout the Health System, as well as facilitating leadership to achieve necessary regulatory and performance excellence audit processes.

• Actively engage in the development and implementation of the strategic plan for Quality Management Systems aligned with the overall strategic plan and ensure the integration of service line planning into applicable service lines. Lead program planning, implementation and evaluation efforts for areas of responsibility at a strategic and tactical level.
• Collaborate with administrative and clinical colleagues in strategic planning and the development and evaluation of quality outcomes, metric management and survey/ regulatory readiness for all services.
• Determine opportunities to improve the value and equity of care and services to patients and families, working collaboratively across organizational lines to facilitate hospital and nursing operations and ensure patient needs are met.
• Promote patient improvement outcomes, comfort and wellness. Ensure exceptional patient experience through patient centered initiatives and support of patient advocate processes.
• Oversee enterprise-wide compliance with ongoing regulatory and accreditation readiness sustaining subject matter expertise regarding understanding of regulatory requirements, State Mandated Guidelines, and accreditation standards.
• Oversee coordination of the efforts for identified committees, departments and clinical service teams in providing feedback and input into response to the DOH, DNV and other accrediting bodies.
• Responsible for the coordination and follow through of regulatory surveys conducted by the DOH as well as collaborating for DNV, CARF, COC and other surveys to ensure responses are congruent with practices throughout the system.
• Will act as contact and disseminate regulatory changes, notification of new regulations and facilitation of the response needed.
• Collaborates with many other departments to ensure compliance with regulatory information.
• Ongoing relationships with DOH, DNV, Administration, Medical Staff, Nursing Staff, Program Directors and/or ancillary services through committees and meetings.
• Serve as the Administrator-On-Call for the Health System throughout the year as scheduled/assigned.
• Make decisions or recommendations related to performance management, hiring, transfers, corrective actions, terminations, etc. In partnership with Human Resources, resolve or ensure the resolution of staff issues and grievances in a fair, timely and consistent manner. Maintain a focus on internal talent management and retention.
• Cultivate a culture that promotes and rewards professional growth, interdisciplinary collaboration, constructive communication, flexibility, teamwork, and customer service.
• Ensure the availability of appropriately trained staff to deliver a high quality, consistent standard of care and regulated care. Provide opportunities for staff development based on scientific advances, changes in technology, society, or health care delivery systems.
• Keep current in best practices through participation in professional associations and learning opportunities. Represent the health system at state, local and national levels.
• Advocate MVHS’s diversity, inclusion and health equity mission, strategies and practices to support a diverse workplace and patient population. Leverage the effects of diversity to achieve a competitive business advantage
• Performs related duties as assigned.