Job Summary

Responsible for comprehensive health system efforts to maintain continuous compliance with regulatory requirements including Joint Commission standards, National Patient Safety Goals, CMS Conditions of Participation, Maryland COMAR, and other regulatory agencies.  Educates hospital staff on regulatory requirements and follow through with compliance to regulations. Actively works with Joint Commission chapter leaders to initiate, develop, and monitor requirements of compliance to regulations.

Promotes a safe, functional and supportive environment within the health system so that quality care and safety are preserved. Assists Health System’s staff to remain in a state of continual readiness for any regulatory survey.

Facilitates and or/supports other quality initiatives of the Accreditation and Regulatory Compliance Division, including but not limited to, Root Cause Analysis and Failure Mode and Effects Analysis.

Ensures compliance with CMS complaints, Department of Health, Office of Health Care Quality Complaints, and Joint Commission Complaints.

This position supports the Frederick Health mission, vision, core values and customer service philosophy and adheres to the Frederick Health Compliance Program, including following all regulatory requirements and the Frederick Health Standards of Behavior.

Essential Functions:

• Acts as point person for tracer process.  Ensures process meets TJC standards. Designs, executes and compiles data regarding mock surveys and tracer activities.

• Interacts/interfaces with all members of the medical staff, nursing and ancillary departments to discuss pertinent issues and follow up of patient events.

• Informs and educates health care leadership, management and staff about regulatory compliance rates, standards, changes in protocol, and implications to practice.

• Maintains current knowledge of TJC, CMS, COMAR, Magnet and NDNQI and assesses compliance throughout the organization.

• Expert in CMS, Joint Commission and other regulatory agencies

• Performs retrospective and concurrent review of specific focused studies (including procedures, diagnosis and other studies) requested by medical staff, hospital departments and committees.

• Provides continued improvement consulting services to customers.

• Collects, interprets and reports data at specified intervals with 99% accuracy and completeness.

• Identifies and interprets objective and subjective data found in the medical records.

• Compares the identified data to established criteria to determine appropriateness of care.

• Abstracts and reports performance improvement information in appropriate format to detect patterns and/or problems in the delivery of care.

• Identifies potential areas for change and improvement of the study design and data collection and makes recommendations.

• Develops new ongoing quality projects and evaluates the appropriateness of indicators and criteria for quality monitoring.

• Maintains current knowledge of performance improvement strategies, principles, methodologies, techniques and data analysis.

• Executes effective improvement projects through multidisciplinary team collaboration

• Active participant in meetings and provides reports and information as required by the committee or team and meets 90% attendance.

• Assures that issues are communicated to appropriate committees or individuals and that issues have timely resolution.  

• Expert in knowledge of types of cases that constitute Level I reportable events to the Maryland Office of Health Care Quality.

• Notifies the Manager of ARC or Patient Safety Officer regarding reportable or potentially reportable events in a timely fashion.

• Facilitates and manages RCA’s and FMEA’s.

• Facilitates and manages the investigation of reportable or potentially reportable events.

• Facilitates teams to identify areas of potential breach of patient safety and create solutions to eliminate such breaches.

• Investigate complaint which includes but not limited to literature research, medical record review, consultation with content experts and interviews

with involved staff/providers.

• Processes complaint in accordance with CMS, OHCA, and The Joint Commission established time frames and requirements.  Develops a written response to each element of the complaint which is returned to the regulatory agency within the specified time.

• Makes referrals to appropriate personnel, interacts with physicians, hospital staff, hospital leadership and the patient in securing resolution to issues.

• Coordinates with Risk Manager on any potentially litigious situation that is identified during the course of the complaint investigation

• Develops and coordinates presentations of complaint activities for appropriate committees and departments regarding trends in the organization. 

• Event report triage - Coordinates requests for information from the Department of Health and Mental Hygiene, CMS, TJC or third party payers related to patient /family complaints.

• Overall organization, planning and controlling of all facility safety-related initiatives and activities.

• Develops and conducts formal training and works with departments to develop and conduct training programs; Helps to ensure a culture of safety.

• Other Duties as assigned

Required Knowledge, Skills and Abilities:

• Strong clinical knowledge and critical thinking skill to evaluate appropriateness of clinical practice.

• Excellent communication skills, both verbal and written.

• Strong organizational skills and ability to prioritize and manage multiple tasks.

• Interacts with physicians, nurses, department heads and others while identifying quality of care issues.

• Applies creative problem solving, identify errors of omission, and utilize resources effectively.

• An understanding of CMS and Joint Commission regulations.

• Ability to abstract data from the medical record and enter data into designated software programs such as Premier, QME, NDNQI and Verge. Proficiency and accuracy in the use of software programs such as MS Word, Excel, and Outlook.   

• Expert knowledge of job/department specific software programs, such as Premier and NDNQI. Should possess a good working knowledge of the internet.

• Works professionally with a diverse population base.

• Maintains a high level of confidentiality.

Minimum Education, Training, and Experience Required:

• Bachelor’s degree in nursing, Information Systems or health care related field required.

• Three to five years of health care experience in a patient care setting with current knowledge of procedures, treatments and medications in those areas.

• CPHQ or HACP certification within 2 years of employment.  

• Previous experience in performance improvement activities including project planning and team facilitation preferred.

Patient Contact:

If applicable, must demonstrate and maintain current knowledge and skills in providing appropriate care/contact for patients in the following age groups:

___Neonate (0 thru 30 days)

___Infant (31 thru 12 months)

___Child (13 months thru 12 years)

___Adolescent (13 years thru 17 years)

___Adult (18 years thru 65 years)

___Geriatric (66+ years)

Position does not require patient contact.  

If applicable, must demonstrate knowledge of the principles of growth and development over the life span and possess the ability to assess data reflective of the patient’s status.  Possess the ability to interpret the appropriate information needed to identify each patient’s requirements relative to his/her age-specific needs and to provide the care needed as described in the unit’s/department’s policies and procedures.

Sedentary - Light Work - Lifting up to 15 pounds on an infrequent basis (less than one lift every three minutes).  While work is mostly done sitting, a certain amount of walking or standing is often necessary.

Ergonomic Risk Factors:

Repetition:  Repeating the same motion over and over again places stress on the muscles and tendons.  The severity of risk depends on how often the action is repeated, the speed of the movement, the required force and muscles involved.

Working Conditions:

Bloodborne Pathogens Exposure Risk:   Category B – MAY have exposure to blood or body fluids.

Reporting Relationship:

Reports to Manager/Director of Accreditation and Regulatory Compliance.

Disclaimer:

The content of this document reflects the general duties, responsibilities, minimum skills, abilities and competencies necessary to perform the essential functions of the job and should not be considered as an exhaustive detailed description of all the work requirements of the position.

Schedule: Mon-Fri  8a-4:30p