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Transplant Quality and Regulatory Affairs Specialist; MSH
Mount Sinai Health System
Location: New York, New York
Type: Full Time
Preferred Education: Masters
Hospital, Public and Private
Internal Number: 2775622
Strength Through Diversity
Ground breaking science. Advancing medicine. Healing made personal.
Roles & Responsibilities:
The Transplant Quality and Regulatory Specialist is responsible for the regulatory compliance and patient safety aspects of the Transplant Program to foster the development of a high reliable organization. Facilitates and participates in the implementation of the multidisciplinary Transplant Program, hospital and system wide Clinical Quality and Patient Safety Performance Improvement Program. This healthcare professional coordinates the planning, monitoring and evaluation of compliance with the New York State Department of Health (NYSDOH), Center for Medicare Services (CMS), United Network for Organ Sharing (UNOS) and other regulatory agencies as required. Participates in planned and unplanned regulatory visit activity. Promotes collaborative practice among departments/services for improved clinical outcomes, processes of care and regulatory compliance.
Oversees and coordinates efforts of the Transplant Program Clinical Quality and Patient Safety Performance Improvement Program.
Facilitates the identification of opportunities for improvement and assist in the design and ongoing measurement of performance indicators and outcomes.
Assists in planning, reviewing, and implementing activities related to the organizational and Transplant Program goals and objectives including Quality and Safety Goals.
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.
Plan, coordinates and reports on a Failure Mode Effect Analysis.
Facilitate and participate in the Transplant Program and MSHS improvement initiatives as appropriate.
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.
Monitors and displays statistical data for quality reports and evaluations.
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.
Regulatory & Accreditation
Uses knowledge of standards of accreditation and regulatory agencies to assist with assessment of compliance. Conduct ongoing assessment of standards compliance including observation, interview and medical record review to engage staff and assess compliance.
Participates in the preparation, planning, coordination and oversight of planned and unplanned regulatory survey and reporting by The Joint Commission, NYSDOH, CMS, UNOS and other regulatory agencies as required.
Develops and facilitates education workshops, meetings or conferences focused on improvement methodologies and regulatory compliance with high impact on the Transplant Program and/or participants; coordinates logistics, scheduling and participant communications.
Develops and writes educational material and communication for distribution for quality and regulatory purposes.
Participates as a member of the hospital Quality Performance and Improvement Committee.
Supports and maintains the quality structure which includes all quality related transplant committees including preparation of documentation and flow of material.
Supports the hospital Quality Performance and Improvement Committee, departmental committees, performance improvement taskforces and organizational improvement teams as appropriate.
Assist with the investigations and responses to quality of care inquiries arising from IPRO and other third party sources and patient complaints/grievances.
Interacts and maintains liaison with students, faculty, staff and outside/community agencies or committees in facilitating program objectives.
Maintains effective communication and working relationships with a wide variety of staff (hospital, medical, ambulatory, behavioral) to support and facilitate quality -related initiatives.
Performs other related duties.
Masters level degree required.
A minimum of 3-5 years progressive experience in a clinical role with patient safety/quality preferred.
Experience as transplant coordinator preferred. Knowledge of CMS/UNOS regulations required.
Experience with CMS/UNOS survey preferred.
Strength Through Diversity
The Mount Sinai Health System believes that diversity and inclusion is a driver for excellence. We share a common devotion to delivering exceptional patient care. Yet we’re as diverse as the city we call home- culturally, ethically, in outlook and lifestyle. When you join us, you become a part of Mount Sinai’s unrivaled record of achievement, education and advancement as we revolutionize healthcare delivery together.
We work hard to recruit and retain the best people, and to create a welcoming, nurturing work environment where you have the opportunity and support to develop professionally. We share the belief that all employees, regardless of job title or expertise, have an impact on quality patient care.
Explore more about this opportunity and how you can help us write a new chapter in our story!
Who We Are
Over 38,000 employees strong, the mission of the Mount Sinai Health System is to provide compassionate patient care with seamless coordination and to advance medicine through unrivaled education, research, and outreach in the many diverse communities we serve.
Formed in September 2013, The Mount Sinai Health System combines the excellence of the Icahn School of Medicine at Mount Sinai with seven premier hospitals, including Mount Sinai Beth Israel, Mount Sinai Brooklyn, The Mount Sinai Hospital, Mount Sinai Queens, Mount Sinai West (formerly Mount Sinai Roosevelt), Mount Sinai Morningside ( Formerly St Luke’s), and New York Eye and Ear Infirmary of Mount Sinai.
The Mount Sinai Health System is an equal opportunity employer. We comply with applicable Federal civil rights laws and does not discriminate, exclude, or treat people differently on the basis of race, color, national origin, age, religion, disability, sex, sexual orientation, gender identity, or gender expression.