Regulatory Assistant Director
Kings County Hospital
Assistant Director of Regulatory Affairs/ Quality Assurance - H+H Kings County Hospital 1/2015 • Administrative management and oversight of day to day operations, update policies and procedures for regulatory standard• Liaison between the hospital and regulatory agencies (TJC, DOH, CMS, NYSDOH, NYCDOH, OMH, OASAS, OPRE, IPRO), monitor quality measures for CMS and regulatory compliance and providing corrective plan of action• Maintain the facility’s continuous survey readiness program structure to ensure adherence to applicable federal, state and local rules and regulations• Tracks and trends compliance outcomes and present to senior and local leadership• Conduct interdisciplinary rounds with Infection Control, Safety and Central Sterile Services• Designing, planning, evaluating programs and implementing performance Improvement Projects with Model for Improvement techniques for new healthcare initiatives • Project management of Patient Safety/ Quality of Care, developing mechanism to increase inpatient nutritional care delivery for malnourished patients and continuity of nutritional care post discharge • Ambulatory Care redesign and driver diagram increasing patient outreach for Treat 2 Target Hypertension program, cycle time reduction and decreasing left without seen scores, and increasing referral rate• Facilitating ICARE (Integrity, Compassion, Accountability, Responsibility and Excellence) Program Model exceeding statewide HCAHPS score by 15%• Increasing capacity building initiatives and promote corporate core values, through education, engagement, and empowerment to leadership, clinical and non-clinical staff and front-line staff