RN Patient Safety & Quality - Regulatory/Accreditation

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Assesses, plans, and implements the functions of the Regulatory Compliance Program and coordinates proactive and reactive regulatory and accreditation efforts to ensure continued improvement of patient care and continued readiness related to government and accreditation regulations. Functions as a resource person for organizational regulatory preparation for surveys, licensure requirements and hospital representative during surveys.

• Regulatory compliance:

- Plans, facilitates, and promotes the comprehensive system of organization wide compliance with Centers of Medicare/Medicaid Services regulations, laws, Joint Commission Standards, license boards and standards.

- In collaboration with the hospital leadership; manage, monitor, revise and implement the organization policies and procedures management system to promote safe and quality care and regulatory compliance.

- Works with department leaders to develop, complete and facilitate monitoring to ensure compliance.

- Assists multidisciplinary personnel and physicians in addressing matters requiring   regulatory advisement, in collaboration, with the organization’s leadership team.

• Standards of services:

- Reviews clinical and non-clinical documents and records to assure compliance with standards of services delivered in the organization and takes steps to assess the risk regarding compliance. Reports critical issues for immediate action and/or administrative action.

- Collaborates with the departmental leaders to educate staff regarding new or updated standards.

• Audits, Assessments and Tracers:

- Performs clinical record audits, risk assessments and clinical and non-clinical tracers to evaluate quality and safety of care and risk of non-compliance.

• Reporting and documentation:

- Compiles reports for the leaders regarding internal and external surveys per defined timeline. Prepares all communication with regulatory bodies.

- Develops and maintains action plans and files regarding licensure and compliance with state, federal agencies and accrediting bodies.

• Data collection and analysis:

- Collects and analyzes data related to the processes that support care and treatment and safety of patients, visitors, employees, contract staff, physicians, students, and volunteers.

EXPERIENCE QUALIFICATIONS

• 2 years of nursing experience in service line required.
• 2 years of education and/or accreditation experience preferred.

EDUCATION QUALIFICATIONS

• Employees or candidates must have either one of these: Bachelor's in nursing (BSN) or Master's Degree in healthcare-related field, or Associate Degree in Nursing.

LICENSES AND CERTIFICATIONS

• Certification Name: Current license to practice as a registered nurse
  • Required
  • Issuer: In Louisiana required
  • Licensure Speciality:
  • Entity:

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  SKILLS AND ABILITIES

• Robust knowledge of performance improvement techniques to facilitate outcomes management and service line excellence.
• Demonstrates effective teaching skills, utilizes principles of adult learning and is committed to mentorship within the service line.
• Experience in performing oversight activities or quality assurance required.
• Excellent written and verbal communication skills and the ability to pay close attention to detail required.
• Must have a track record of producing work that is highly accurate, demonstrates attention to detail and reflects well on the organization.
• Computer experience should include Microsoft Word, Excel, PowerPoint and Outlook at the intermediate level, at a minimum.
• Must be flexible and able to adapt to frequently changing standards and priorities.
• High degree of independence, flexibility, initiative and commitment.
• Must demonstrate strong customer service orientation.
• Experience with e-learning, Cerner and Simulation preferred.

WORK SHIFT:

Days (United States of America)

LCMC Health is a community. 

Our people make health happen. While our NOLA roots run deep, our branches are the vessels that carry our mission of bringing the best possible care to every person and parish in Louisiana and beyond and put a little more heart and soul into healthcare along the way. Celebrating authenticity, originality, equity, inclusion and a little “come on in” attitude is the foundation of LCMC Health’s culture of everyday extraordinary

About West Jefferson Medical Center