Director, External Quality and Safety Programs and Reporting - Quality & Safety - Memorial Sloan Kettering Cancer Center

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Director, External Quality and Safety Programs and Reporting - Quality & Safety

The Director, External Quality and Safety Programs and Reporting is an excellent leadership opportunity with our Quality & Safety team.

Role Overview:

• In partnership with the VP of Quality and Safety and in partnership with MSK Clinical Departments and Regulatory Affairs, this role is responsible for the oversight, strategic direction, and leadership for the following programs: Center for International Blood and Marrow Transplant Research (CIBMTR), the Foundation for the Accreditation of Cellular Therapy (FACT), and other external programs as determined.
• The Director provides leadership to and oversees compliance with regulatory requirements, development and implementation of standards, policies, and procedures, coordination of external program Quality Management initiatives and serves as liaison with outside agencies and contracted payers.
• This role also coordinates the collection of and analysis of relevant data with other MSK teams collecting similar data for other reporting needs.

Clinical Quality and Performance Improvement Strategy and Execution for Relevant External Programs -

• Provides leadership and oversees the external reporting of the Blood and Marrow Transplant Clinical Program, the Foundation for the Accreditation of Cellular Therapy (FACT), and other external programs as determined.
• Ensures compliance with regulatory requirements, development and implementation of standards, policies and procedures, coordination of BMT Quality Management initiatives and serves as liaison with outside agencies and contracted payers.  Ensures ongoing FACT accreditation.
• In collaboration with Regulatory Affairs, responsible for departmental compliance with New York State Department of Health regulations, The Joint Commission (TJC) Performance Improvement and National Patient Safety Goals chapters, CMS Conditions of Participation, NY and NJ Departments of Health codes rules and regulations and other regulatory/external agency requirements (e.g., FACT) by ongoing monitoring and evaluation, establishing work plans as required and prioritizing their implementation.
• Acts as designated contact person for relevant external programs and agencies (i.e., FACT, CIBMTR).
• Facilitates FACT site visits. Provides support for scheduled and unscheduled site visits with regulatory bodies such as the DOH, TJC, CMS, etc., as needed.
• In conjunction with Dept. of Nursing, responsible for interpreting and reporting Magnet nursing metrics to Quality and Hospital Leadership.
• Reviews, develops, and implements policies and procedures to enhance Quality and Safety with external programs.
• Collaboratively leads the identification and development of Performance Improvement initiatives to enhance the management and execution of programs that require external certification.

System, Operational, Data, and Project Management Oversight and Execution for Relevant External Programs -

• Responsible for the collection, validation, and analysis of performance data required for external stakeholder submissions (regulators, registries, accreditors, certifications, etc.). Coordinates with leaders of other programs who collect similar data for different reporting purposes etc.
• Directs the collaboration with internal and external stakeholders to ensure accurate, complete, consistent, and timely submissions to external organizations.
• Ensures teams continuously informed of updates to guidelines, regulations, and other quality reporting, regulatory, or accreditation requirements.
• Leads the identification of trends, benchmark performance against national standards, and reports outcomes to internal and external stakeholders.
• Directs the preparation of documentation and reports as necessary for external audits/site visits by regulatory agencies and accrediting bodies.
• Serves as department liaison for external quality/patient focused committees/workgroups including the GNYHA Quality and Outcomes Committee and the Comprehensive Cancer Center Consortium (C4QI). Disseminates necessary information from those organizations to the Division of Quality & Safety staff, MSK staff (as relevant) and MSK Hospital Administration.

Staff Management –

• Provides leadership for the External Quality and Safety Program and Reporting team members.
• Plans, guides, and manages the functions, resources, and activities of the team to meet institutional and department goals, objectives and timelines including recruitment, training, and overall management of team members.
• Establishes goals and priorities, measurements, and benchmarks to define success for the team.
• Provides direct reports with guidance, mentoring, and performance feedback as well as development opportunities.
• Builds the capability of the team to meet current and future needs of MSK.

Key Qualifications:

• RN (NY) License or other clinical experience
• Master's degree in Nursing, Nursing Administration, Healthcare, or relevant area with more than 10 years experience in a complex clinical environment.
• 5 years' of management experience required; 3 years’ of progressive and results-oriented experience in Quality.

Core Skills:

• Proven track record of excellent application of improvement and patient safety science; experience working with performance improvement tools and methodologies, familiarity with current trends, and ability to implement them required.
• Working knowledge of applicable safety rules and regulations.
• Experience in treating patients undergoing BMT.
• Expertise in high-reliability principles and concepts.
• Ability to explain complex clinical issues to non-clinical staff.
• Excellent leadership skills are essential.
• Demonstrates a high commitment to quality.
• Excellent judgment and decision-making skills.

Additional Information:

• Location: Hybrid / 633 Third Avenue, NYC
• Schedule: Monday - Friday, 9 am - 5 pm
• Reporting to the Vice President of Quality of Safety

Pay Range: $193,800 - $329,500/annually

Helpful Links:

• MSK Compensation Philosophy
• Review Our Greats Benefits Offerings

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