Sr. Director, Quality, Safety, Regulatory Affairs
Company: UMass Memorial Health Care
Posted on: February 23, 2021
Sr. Director, Quality, Safety, Regulatory Affairs Position at
UMass Memorial HealthAlliance-Clinton Hospital At UMass Memorial
Health Care, Everyone is a Caregiver regardless of title.
Exceptional patient care, academic excellence and leading-edge
research make UMass Memorial the premier health care system of
Central and Western Massachusetts, and a place where we can help
you build the career you deserve. We are more than 14,000
employees, working together as one health care system. And
everyone, in their own unique way, plays an important part,
everyday. Title:--Sr. Director, Quality, Safety and Regulatory
AffairsDepartment: Office of Quality Patient Safety Requisition #:
211830 Hours: 40
Location:HealthAlliance-Clinton Hospital, Leominster Campus
HealthAlliance-Clinton Hospital is part of the UMass Memorial
Health Care system.-- Serving northern central Massachusetts, we
are committed to improving the health of people through excellence
in care and comprehensive health services. Promoting healthy
lifestyle habits, we serve as a role model by having a tobacco and
smoke free campus and hiring nicotine free employees. By exploring
careers with us, you are committed to giving your best to our
patients, our community and everyone working on our
HealthAlliance-Clinton Hospital Care Team. Whatever your career
choice, know that at HealthAlliance-Clinton Hospital you can make a
- Position Summary: This position is responsible for the overall
operation and administration of Quality, Patient Safety, Medical
Staff Peer Review, Infection Control, and Regulatory Affairs
including Accreditation Services, Quality and Safety Accreditation
programs and Regulatory Quality and Safety Analytics. This position
ensures the continual improvement of clinical processes to evaluate
and improve the quality of health care evaluation, reporting of
clinical quality indicators, infection control and prevention.
Responsible for the coordination and oversight of activities to
achieve external accreditation, as well as associated and specified
regulatory processes. Additionally, this position is responsible
for the submission of data under the general topic of Pay for
Performance, Core Measures (etc.) and for leading efforts to
optimize such performance. The position also functions as the PCAC
Coordinator for the organization. As a member of the Quality and
Regulatory Affairs Management Team, this position is responsible
for contributing to the development and execution of strategies and
goals for the division. This position works with System leaders to
- Develops proactive risk assessment and reduction strategies and
programs, as well as responds to the need for development/revision
of policies, processes or systems.--
- Develops educational and informational programs and materials
designed to educate Physicians, Nurses and other staff about
Performance Improvement, Regulatory Requirements, National Patient
Safety Goals, CMS Conditions of Participation, Core Measures, Value
Based Purchasing, The Joint Commission Standards, as well as other
metrics/topics as necessary.
- Directs External Accreditation preparation activities as a
coordinated, ongoing process. Delegates specific responsibilities
and functions to teams, committees, and departments, and assures
these areas meet regularly to review standards and achieve and
maintain necessary results in all areas. Develops tactics to meet
new standards/regulatory reporting needs within the appropriate
- Participates in the design, communication, implementation and
evaluation of the hospital's quality improvement programs and
projects. Coordinates and oversees such efforts throughout the
hospital and related entities to ensure compliance.--
- Evaluates the Performance Improvement program and Compliance
Work Plan at least annually for Board approval.
- Ensures/facilitates continual improvement activities related to
regulatory quality metrics/data.
- Participates in strategic planning for the Quality
- Manages personnel and processes related to data abstraction and
reporting for CMS, MassHealth and other agencies as required.
- Maintains thorough knowledge of regulatory and accrediting body
requirements. Interprets new laws, standards, and regulations in
order to direct the development, revision, communication, and
implementation of new policies, processes, or systems to ensure
ongoing achievement of these external requirements. Works with
other directors to understand the interrelationships between
achieving external standards and resource utilization and advises
senior management on the impact of any trade offs which are
- Maintains a collaborative, team relationship with all levels of
hospital management, employees, and physicians in order to
effectively contribute to the group's achievement of goals and to
help foster a positive work environment. Serves as primary contact
for patient complaints from intake to resolution and teaching.
- Coordinates with the healthcare system as to the development
and modification of a Risk Management program to meet the needs of
- Develops and utilizes performance metrics to continually
improve quality and operating efficiency.
- Acts as consultant for Management, the Medical staff and Senior
Management Team on issues of quality improvement, patient safety,
risk management, care coordination, corporate compliance, and
external accreditations and recommends annual quality
- Consults with UMMHC System-level experts and overseers within
the scope of their duties as needed and prudent, including but not
limited to Quality, Safety, Risk, Regulatory Affairs, legal and
- Works in conjunction with HAC Chief Compliance Officer and/or
HAC Board on all compliance concerns re: quality, safety or
- Directs projects such as Pay for Performance to maximize
dollars and improve quality.
- Serves as leader for assigned quality and safety meetings.
- Coordinates and directs the work of the Manager of Infection
Control and Prevention to ensure the organization meets all
relevant standards and pursue best practices consistent with UMMHC
goals and national patient safety standards.
- Directs and supervises assigned personnel including performance
evaluations, scheduling, orientation, and training. Makes
recommendations on employee hires, transfers, promotions, salary
changes, discipline, terminations, and similar actions. Resolves
grievances and other personnel problems within position
- Develops and recommends the budgets for the areas managed.
Manages activities to assure financial goals are met.
- Coordinates the assignment of tasks and helps resolve technical
and operational problems. Evaluates the impact of solutions to
ensure goals are achieved.
- Provides effective direction, guidance, and leadership over the
staff for effective teamwork and motivation, and fosters the
effective integration of efforts with system-wide initiatives.
- Meets established productivity standards.
- Facilitates and promotes the sharing of knowledge and content
- Takes responsibility for ensuring that all work outcomes
satisfy the UMass Memorial Health System True North.
- The individual must support the mission, vision, and goals of
HealthAlliance-Clinton Hospital and serve as a role model for CARES
- Adheres to change control processes.
- Participates in cross training to optimize department
- Demonstrates excellent attendance and actively participates in
a variety of meetings and training sessions as required.
- Demonstrates a friendly, responsive, service-minded attitude to
all internal and external customers.
- Communicates ideas effectively. Shares information and keeps
others properly informed. Gives, and is open to useful
- Adheres to the HealthAlliance-Clinton Hospital Code of Conduct
and Behavior Standards and dress code.
- Complies with established environment of care/safety policies
and procedures and all health and safety requirements.
- Maintains and fosters an organized, clean and safe work
- Contributes to the development and application of process
- Maintains a collaborative, team relationship with peers and
colleagues in order to effectively contribute to the group's
achievement of goals and to help foster a positive work
- Attends staff meetings and in-service programs as required or
directed. Keeps current with hospital and unit changes by reading
communication boards and/or books, bulletin boards, posted notices
and reads and responds to e mails on a regular basis.
- Practices cost containment and fiscal responsibility through
the efficient use of supplies, equipment, time, etc.
- Encourages and supports diverse views and approaches, creating
an environment of professionalism, respect, tolerance, civility and
acceptance toward all employees, patients and visitors.
- Integrates diversity into departmental objectives, such as
hiring, promotions, training, vendor selections, etc.
- Participates in performance improvement initiatives and
demonstrates the use of quality improvement in daily
- Ensures compliance with regulatory agencies such as Joint
Commission, DPH, etc. Develops and maintains procedures necessary
to meet regulatory requirements.
- Ensures that department complies with hospital established
policies, quality assurance programs, safety, and infection control
policies and procedures.
- Ensures adequate equipment and supplies for department.
- Develops and maintains established departmental policies,
procedures, and objectives.
- Ensures compliance to all health and safety regulations and
- Performs similar or related duties as required or directed. All
responsibilities are essential job functions.
- Position Qualifications: License/Certification/Education:
- Clinical background preferably as a RN
- Certified Professional Healthcare Quality (CPHQ) certification
- Minimum seven (7) years of management or director level
experience including quality, risk management, compliance, case
management, regulatory affairs, and external accreditation process
within MA acute care hospitals.
- Minimum five (5) years of conducting complex compliance (or
- Familiarity with state, federal and accrediting body
regulations in healthcare.
- Possesses and applies the skills and knowledge necessary to
provide care to patients and customers throughout the life span,
with consideration of aging processes, human development stages and
cultural patterns in each step of the care process.
- Knowledge of peer review standards, quality of care and
performance improvement processes.
- Knowledge of current clinical standards of practice.
- Ability to implement an improvement plan, supervise and educate
others during implementation, and to assess the plan's
- Ability to influence change without direct authority.
- Ability to prepare and present to large and small audiences,
and to effectively facilitate meetings.
- Excellent interpersonal, communication, and organizational
- Ability to work independently and as a team member.
- Ability to manage multiple priorities and deadlines.
- Ability to communicate clearly, accurately, and succinctly
verbally and in writing.
- Excellent analytical skills.
- Proficient with computer programs and applications (Word,
Excel, Outlook, Internet Explorer).
- Ability to read, write and speak clearly in English.
- Possesses and applies the skills and knowledge necessary to
provide care to patients and customers throughout the life span,
with consideration of aging processes, human Unless certification,
licensure or registration is required, an equivalent combination of
education and experience which provides proficiency in the areas of
responsibility listed in this description may be substituted for
the above requirements. Standards of Respect: We're striving to
make respect a part of everything we do at UMass Memorial - for our
patients and for each other. We're expecting that our new
caregivers practice our six Standards of Respect: Acknowledge,
Listen, Communicate, Be Responsive, Be a Team Player, and Be Kind,
to help us make respect a part of how we take care of business
everyday. As an equal opportunity and affirmative action employer,
UMMHC recognizes the power of a diverse community and encourages
applications from individuals with varied experiences, perspectives
and backgrounds. All qualified applicants will receive
consideration for employment without regard to race, color,
religion, gender, sexual orientation, national origin, age,
disability, gender identity and expression, protected veteran
status or other status protected by law.
If you are unable to submit an application because of incompatible
assistive technology or a disability, please contact us at
firstname.lastname@example.org . We will make every effort to
respond to your request for disability assistance as soon as
possible. You have been redirected to a UMass Memorial Health Care
Keywords: UMass Memorial Health Care, Jackson , Sr. Director, Quality, Safety, Regulatory Affairs, Executive , Clinton, Mississippi
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