Admin Patient Safety and Regulatory

Position Summary

Reporting to the Director of Regulatory Affairs in the Department of Regulatory Affairs & Patient Safety, the Admin for Patient Safety & Regulatory supports the department in coordination with hospital leadership, through management of projects and support activities related to patient safety and regulatory risks.

The department will utilize the Admin’s expertise to help identify opportunities and risks and organize large- and small-scale projects to address these priorities. In this role, they are expected to partner with subject matter experts to develop detailed action plans for major safety & regulatory initiatives, review and update associated policies and procedures, assist colleagues, chapter leaders, department heads and other campuses in planning and executing structured and comprehensive initiatives. The goal of their efforts is to ensure compliance with new and evolving regulatory requirements in alignment with accreditation and certification program standards.

Duties of a Admin for Patient Safety & Regulatory may include the following but are not limited to:

· Responsibilities include collaboration on and coordination of organization-wide efforts to develop and manage patient safety and regulation driven assessments, processes, and policies across the health system

· Organizes and participates in mock audits and mock surveys within inpatient and outpatient environments to assess continuous readiness for announced and unannounced visits from regulatory agencies

· Works with stakeholders to initiate immediate and long-term action plans in response to identified opportunities or survey findings from accreditation and certification program visits. Manages associated data collection tools and reporting as outlined in corrective action plans

· Creates and maintains comprehensive documentation for assigned projects including goals/objectives, interventions/implementations and measurable progress through project completion

· Performs duties to help ensure a reliable and successful project implementation covering the total scope of project.

· Organizes and facilitates tracers, meetings and workgroups to support accreditation and certification programs, as assigned.

· Assists with the interpretation and dissemination of regulatory updates and their impact on workflows.

· Develops education and communication materials related to policy changes, accreditation requirements, and regulatory compliance

Qualifications

Required Qualifications:

· Bachelor’s Degree in Nursing or related healthcare field; or other health profession.

· Experience with one or more quality improvement models or methodologies (i.e., Lean, Six-Sigma, Model for Improvement/Plan-Do-Study-Act).

· Five (5+) years of work experience in a health care clinical, administrative or project management.

· Experience participating in regulatory and patient safety projects and programs in the inpatient or outpatient setting.

· Strong oral and written communication skills

· Strong data analytic skills

· Strong group leadership and organization skills

· Innovative thinking, facilitation, and consensus building skills

· Ability to work well both independently and as a part of a team

· Ability to analyze and present data and program information, orally and in writing in non-technical language

Preferred Qualifications:

· Master’s degree in Nursing or other health profession

· Certification in one of the following disciplines: Lean, Six-Sigma, Model for Improvement/Plan-Do-Study-Act)

· Certified Professional in Healthcare Quality (CPHQ) and/or Certified Professional in Patient Safety (CPPS) preferred.