Director of Nursing Quality, Safety & Regulatory Compliance

The Director of Nursing Quality, Safety & Regulatory Compliance reports to the Assistant Vice President of Nursing Practice and Innovation, and is responsible for enhancing and evaluating the clinical quality and safety outcomes of nursing practice through the use of clinical data management and review throughout Maimonides Health.  In addition, the Director of Nursing Quality, Safety and Regulatory Compliance is responsible for developing systems and processes, which ensure continual survey readiness and regulatory compliance.  In this role, the incumbent partners effectively with Organizational Effectiveness, Human Resources, Nursing Education, Enterprise Quality & Safety and the Senior Nursing Leadership Council to ensure alignment with the changing healthcare landscape and the organization's strategic priorities and direction.

Required Leadership Competencies

1. Communication: Strong written and verbal skills are demonstrated in reports, correspondence and presentations. Ensures staff are kept informed of Maimonides Health and departmental priorities. Communicates vision statement and medical center strategic priorities and demonstrates commitment toward their achievement.
2. Professional Development: Participates in conferences, workshops, and other professional development activities to maintain licensure and/or remain professionally current with advances in field of expertise.
3. Staff Development: Ensures nurse leaders receive training and education to develop their professional competences and personal wellbeing.
4. Problem Solving: Recommendations and decision making reflect strong analytical skills and focus on quality, engagement, cost containment, and impact of change on other departments.
5. Customer Service Management: Incorporates the Maimonides Health’s Customer Service goals in developing and/or revising education policies and systems. Continually reviews the service delivery process to exceed customer expectations. Is perceived as a role model by staff, peers in customer service leadership.
6. Project Management: Participates in multidisciplinary task forces, committees and projects, demonstrating team spirit and ability to work with different internal customers. When leading a project team, demonstrates the ability to bring together different views and skills toward timely and effective completion of project objectives.

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RESPONSIBILITIES

• Plans, coordinates, directs and evaluates effectiveness of regulatory survey readiness plans and activities across sites.

• Partners with nursing education on orientation program and to implement quality, safety and regulatory action plans as appropriate

• Collaborates with the Sr. VP of Nursing and VP of Nursing to ensure that standards set by regulatory agencies (e.g., The Joint Commission) are met and that mandatory educational programs fulfill regulatory agency requirements.

• Develops annual budget for the department; manages budget throughout the year, analyzing and monitoring monthly reports and overtime runs for the department to ensure department operates within budget guidelines.

• Identifies needs and recommends changes for more efficient delivery of high quality and safe care, serves as resource person for regulatory surveys.

• Acts as liaison between Enterprise Quality & Safety and other departments regarding Quality, Safety & Regulatory readiness.

• Maintains established departmental policies and procedures, objectives, quality assurance program, safety, environmental, and infection control standards.

8. Programs: Provides leadership and support for and/or leads initiatives to achieve and maintain Magnet or Pathway to Excellence (PTE) Programs.

9. Seeks and partners for submission in grant opportunities that will support the evolution of the Division of Nursing.

• Provides significant senior nurse leader support for professional governance council implementation and sustainment, supports Magnet program.

          OTHER JOB DUTIES

          Serves as role model for educators and staff.

          Secures, evaluates and maintains institutional, departmental and reference materials for the department of Patient            Services.

          Conducts/directs special projects as assigned.

          Performs other related duties as required

Education:

• Bachelor of Science Degree in Nursing (required)
• Master’s degree in Nursing or closely related field (required)
• Doctoral degree of Nursing Practice (Preferred) and Advanced Nursing Practice degree/certificate from an accredited program (Preferred)

Licenses and Certifications:

• RN - Registered Nurse - State Licensure and/or Compact State Licensure (Required)
• Nurse Leader certification within 1 year (Required)
• National certification in a recognized clinical specialty within 1 Year (Preferred)
• CPR - Cardiac Pulmonary Resuscitation (includes BLS) for healthcare providers from either the American Heart Association (AHA) or American Red Cross within 90 Days (Required)
• ACLS - Advanced Cardiac Life Support Certification (Preferred)

Experience:

Minimum of 3 years of leading projects and initiatives (required)

Experience leading regulatory survey process (required) and lean six-sigma training (preferred)