Patient Safety and Regulatory Compliance Coordinator

Day (United States of America)Patient Safety and Regulatory Compliance CoordinatorThe Patient Safety and Regulatory Compliance Coordinator is a qualified individual who, under the direction of the Manager of Regulatory Compliance and Infection Prevention, is responsible for monitoring regulatory compliance requirements and patient safety functions in all levels of care and locations across Halifax Health. The specialist is responsible for providing a planned, systemic approach to identifying, designing, measuring and monitoring process improvement activities related to patient safety and accreditation standards compliance while advancing the capabilities of the management staff to execute these concepts. This team member has a comprehensive understanding of data and analytic tools as well as health care information systems and technology with an advanced ability to apply these methodologies to extrapolate data, analyze and report in a meaningful format to inform and drive performance improvement activities. The scope of work includes education and training on patient safety, accreditation; data management for the investigation, analysis and monitoring of never event prevention activities; and compliance with accreditation standards/guidelines. Responsible for planning, implementation & monitoring of interventions to ensure evidence-based practices are implemented for standards compliance and participates in and/or leads performance improvement committees as directed. Functions as a key member of the Patient Safety and Quality team.The Specialist will establish and maintain ongoing audits and surveillance of all areas to ensure compliance with all relevant regulatory and accreditation groups (Center of Medicaid and Medicare Services, Agency for Health Care Administration, The Joint Commission, or others as directed).

• Maintains knowledge of standards, updates to standards, compliance of regulatory requirements

• Responsible for performing patient safety surveillance rounds, safety prevention education activities as well as activities to control breaches in prevention measures for the safety and well-being of patients, visitors and Team Members.

• Collect and analyze data collected in the organization related to survey activities including survey readiness rounds. Support the creation, analysis, maintenance, and reporting of corrective action plans in response to findings.

• Provide guidance to Team Members including leaders and physicians to ensure understanding of regulatory requirements and patient safety standards.  Act as a resource for all accreditation and patient safety activities/endeavors.

• Act as a liaison with The Joint Commission and other regulatory agencies as assigned.

• Assist with policy and procedure development and/or review to ensure compliance and alignment with regulatory requirements and Infection Prevention and Control.

• Participate in investigations of identified issues, gaps in adherence to standards, and reported issues. 

• Consult with appropriate departments to ensure adequate and compliant documentation regarding regulatory compliance and patient safety related requirements.

• Annually participates in the evaluation of the patient safety system to ensure a highly reliable approach to patient safety and the journey to zero harm.

• Assists with data management, performance improvement, medical record review and meeting organization to help ensure initiative success and goals are met. Utilizes appropriate reports to coordinate projects for Patient Safety and Regulatory Compliance.

• Provides concurrent Patient Safety and Regulatory Compliance case reviews and recommendations to ensure that evidence based best practices are implemented timely. Complete and analyze patient safety event timelines, root cause analysis timelines, review events, and identify care variation in case reviews.

• Demonstrates commitment to SCIE and protecting patients and providers by advocating safe practices and policies.

• Holds paramount the safety, health, and welfare of the public in the performance of professional duties and escalates safety concerns to appropriate leadership, up to and including executives, with honesty and integrity.

• Other duties as assigned.

• Registered Nurse preferred or at least 3 years of relevant experience in an acute care facility with multiple levels of care or multiple types of services provided such as ambulatory care, homecare, hospice, ambulatory surgery, and other specialty services.

• Competent in performance measurement, and statistical analysis of clinical data required.

• Strong knowledge of evidence-based patient safety practices and standards.

• Proven experience with Patient Safety and The Joint Commission accreditation requirements as well as CMS Conditions of Participation.

• Experience working closely with physicians and other clinical care providers in group and one-on-one settings.

• Strong communication skills (both verbal and written), including those in conflict resolution and management.

• Motivational and team building skills.

Education: Bachelor's degree in nursing, Public Health or related field required, master's degree in related field preferred or 5+ years of Acute Care nursing experience.

Certification: If not already obtained, Certified Professional in Patient Safety (CPPS) or CPHQ (Certified Professional in Healthcare Quality) within 2 years

Required Experience/Skills:

• Working knowledge of state, federal and national accreditation standards in a hospital setting.

•  2-4 years of experience with accreditation surveys in a lead, scribe or escort capacity.

• 1-3 years in project management, performance improvement methodologies. 

• Ability to interpret and practically apply regulatory and infection prevention standards/requirements.

• Knowledge of evidence-based best practices and improvement strategies for reducing patient harm and maintaining accreditation compliance

• Ability to provide professional presentations to executive leadership teams, including reports for complex data analysis

• High proficiency with Microsoft Office suite, especially Excel, Visio, PowerPoint