Quality Improvement Program Manager

Job Description

Strength Through Diversity

Ground breaking science. Advancing medicine. Healing made personal.


Roles & Responsibilities: 


Responsible for supporting the quality structure of the hospital by working strategically and in collaboration with clinical, core department service lines, interdisciplinary committees and high priority work groups to facilitate, implement and evaluate clinical and operational process improvement initiatives at the Mount Sinai Hospital. The Quality Improvement Program Manager reports to the Director, Quality Assurance and Performance Improvement. Duties and Responsibilities


1. Provides leadership in designing clinical work processes that support and optimize quality and performance on initiatives aligned with Hospital goals.

2. Works collaboratively with leadership and staff across the hospital to plan, develop and implement appropriate clinical integration programs.

3. Educates Clinical Performance Improvement teams, Quality Committees, and Department Quality personnel on matters pertaining to clinical improvement: performance improvement strategies, methodologies, team functioning, trends and opportunities.

4. Works to ensure the utilization of clinical data to support the identification of quality issues and improvement opportunities, drive prioritization and decision making, and monitor improvement activities.

5. Consults with hospital directors/managers for best practices and facilitates implementation efforts.

6. Provides direction and guidance to clinical personnel; and develops and oversees the processes associated with clinical outcomes measurement, reporting and improvement.

7. Identifies problems and issues and communicates them to the appropriate individual(s), recommends and implements solutions.

8. Works in collaboration with Risk Management to develop and incorporate pro-active risk reduction processes into clinical department quality.

9. Assist with accreditation, regulatory, and licensing standards related to the delivery of safe and effective patient care. Responsibilities include assisting in overseeing NYS DOH regulatory and accreditation visits such as Joint Commission, NYSDOH and CMS to ensure the appropriate staff and managers are involved, that processes are facilitated at all times during regulatory visits and to develop and monitor compliance with action plans designed to address statements of deficiencies and as a result of root cause analysis.

10. May chair or participate in Hospital quality committees.

11. Performs other related duties as needed.



  1.       Bachelor's Degree required, Master's degree preferred (Nursing, Public Health, Clinical Informatics)
  2.       Minimum Related Experience (5 years of experience in Quality Improvement; experience in program management. Minimum Computer Skills (provide program and skill level, e.g. MS Word - Basic) (skill levels are Basic, Intermediate, Advanced) Advanced MS Office (Word, Excel, PowerPoint), Outlook
  3.       RN license preferred

General Skills:

  1.       Excellent written and oral communication skills
  2.   .   Process improvement skills (Six Sigma, Lean, or CPHQ preferred)
  3.       Project management experience with process measurement, clinical data  collection, process change and working knowledge of regulatory requirements preferred.
  4.       Analytical and problem solving skills
  5.       Ability to work well in a team setting




Strength Through Diversity


The Mount Sinai Health System believes that diversity 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 medicine together.


We work hard to acquire and retain the best people, and to create a welcoming, nurturing work environment where you can develop professionally. We share the belief that all employees, regardless of job title or expertise, can make 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 hospital campuses, including Mount Sinai Beth Israel, Mount Sinai Beth Israel Brooklyn, The Mount Sinai Hospital, Mount Sinai Queens, Mount Sinai West (formerly Mount Sinai Roosevelt), Mount Sinai St. Luke’s, and New York Eye and Ear Infirmary of Mount Sinai.


The Mount Sinai Health System is an equal opportunity employer. We promote recognition and respect for individual and cultural differences, and we work to make our employees feel valued and appreciated, whatever their race, gender, background, or sexual orientation. 


EOE Minorities/Women/Disabled/Veterans



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