Job Description

Steward Health Care System

Job Description

TITLE: Director of Quality and Regulatory Affairs




REPORTS TO: Vice President, Medical Affairs

DATE: February 8, 2016


Responsible for the oversight of Quality and Regulatory Compliance within Carney Hospital. Organize, develop and implement risk mitigation strategies that take into consideration current regulatory climate, ensuring high quality of care that is consistent with both external and internal standards. Works collaboratively with CNO/COO, Medical Director and Program Directors.


  • Maintains strong knowledge of current regulatory requirements and trends, acting as a resource to all Department Directors and staff in order to ensure that Carney Hospital is in compliance with all regulatory requirements.
  • Oversees the process of updating policies and procedures in accordance with all regulatory and accreditation requirements, ensuring that these are appropriately disseminated and implemented.
  • Work with system leaders, Department Directors and Medical Director to develop quality goals and standards of care for the patient population served by Carney Hospital.
  • Provide education and coaching for front line clinical leadership in maximizing performance within the clinical decision support system.
  • Conduct quality assurance chart reviews, assessing clinical and medical documentation to ensure compliance with regulatory and program standards.
  • Provide guidance to clinical leaders and task forces while promoting accountability for achievement of targets for publicly reported measures, including, but not limited to CMS, DMH and Joint Commission Core Measures.
  • Recommends performance improvement activities in collaboration with hospital leadership to insure quality and safety processes are coordinated in a multidisciplinary fashion.
  • Provides oversight on pre-admission decisions and case reviews to assure services are provided in accordance with policies, procedures and regulatory requirements. Identifies best practices and works with all departments to ensure consistency.
  • Provide support in the implementation of an integrated database designed to promote more timely and accurate information related to patient safety issues and quality challenges at the local level.
  • Supports the collection of patient safety data for trends and recommends changes, as appropriate, thereby improving the safety of care at the hospital.
  • Fosters and maintains collaborative relationships with external agencies, purchasers, and stakeholders related to quality, performance improvement and safety initiatives.
  • Coordinate the regulatory compliance program to meet the standards identified by the TJS, CPH, and CMS. Support project structure to insure all staff is involved in regulatory readiness on a daily basis. Work with administrative and clinical leadership to insure they recognize their role in preparation for regulatory readiness.
  • Reviews and evaluates services to ensure that safety and regulatory recommendations are implemented and desired results are obtained.
  • Oversees the infection control program to insure practice is consistent with regulating bodies.
  • Works to support the medical peer review process in association with the hospital VPMA and coordinates reporting to the Board of Registry of Medicine or Department of Public Health.

  • Demonstrates respect and regard for the dignity of all patients, families, visitors, and fellow employees to ensure a professional, responsible, and courteous environment.

1. Commits to recognize and respect cultural diversity for all customers (internal and external).

2. Communicates effectively with internal and external customers with respect of differences in cultures, values, beliefs and ages, utilizing interpreters when needed.


  • Highly motivational communication skills accompanied by the ability to analyze and present data to influence behavior, stimulate innovation, promote best practices, and drive organizational change.
  • Excellent presentation style, including the ability to present data to clinicians and staff at all levels of the organization.
  • A highly skilled change agent with demonstrable sensitivity to the interpersonal, group dynamic, organizational, political, and perceptual issues associated with change.
  • Results orientation accompanied by the skill set required to conceptualize, implement, and operationalize a user-friendly clinical excellence and patient safety program.
  • Demonstrated ability to create and sustain momentum through relationship building, and collaborative management.
  • Expertise in project management at system and local level


  1. Education: Master’s in a health care field, or RN with Masters Degree, or equivalent
  2. Experience (Type & Length): 5-10 years experience in a clinical leader position with a strong foundation in quality

Application Instructions

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