Overview:
USA Health is Transforming Medicine along the Gulf Coast to care for the unique needs of our community.
USA Health is changing how medical care, education and research impact the health of people who live in Mobile and the surrounding area. Our team of doctors, advanced care providers, nurses, therapists and researchers provide the region’s most advanced medicine at multiple facilities, campuses, clinics and classrooms. We offer patients convenient access to innovative treatments and advancements that improve the health and overall wellbeing of our community.
Responsibilities:
Initiates and leads the standards compliance program for the continuous compliance of regulatory standards through the development, Implementation and sustainment of proactive corrective improvements according to the mission and vision of the organization; communicates and uses appropriate customer relation skills with physicians, patients, families and co-workers; responds timely to text messages, emails and pages; coordinates the communication to leadership and management when external surveyors arrive to include an up-to-date contact list used during the survey; collaborates with the Director/Assistant Director, Department Directors and Managers regarding plans and activities to stay continuously survey ready; communicates the results of audits and monitors results related to the regulatory requirements of the Joint Commission (TJC) and Center for Medicare and Medicaid Service (CMS) in reportable formats with trend analysis and benchmarks to identify opportunities for improvement; collaborates with the accreditation consultants and Standards Interpretation Group (SIG) to address organizational issues and/or action plans; provides consultation, education and support to all levels of leadership and staff to accomplish survey readiness goals through practice sessions and tracer activities aimed to increase knowledge and enhance performance level for staff during survey; disseminates TJC and CMS updates to appropriate departmental heads and leadership; informs and collaborates with Health Information Technology to ensure the electronic medical record adheres to TJC and CMS regulatory requirements; collaborates with Staff Development/Quality Management to ensure the TJC compliance and the National Safety Goals are addressed in the Patient Safety Fair and Health Stream education; plans/presents material to new employees at orientation as related to survey readiness; develops and broadcasts Intranet education for physicians, nurses and staff to enhance a culture of continuous survey readiness; develops and facilitates TJC Survey Leadership Sessions to explore current survey methodologies as it relates to organizational systems, infrastructure and key processes that contribute to the quality and safety of care, treatment and services; coaches staff to facilitate an understanding of how daily work activities align with TJC Standards for the safety of patients through “collective mindfulness” by doing the right thing the first time; updates the Joint Commission (TJC) application online based upon facility changes annually; coordinates the development of action plans related to the annual self-assessment and consultant site visits; prepares and enters final scoring for the TJC annual self assessment annually; prepares and assembles the required documentation for the binders utilized for the survey site visit; prepares reports related to the following: National Patient Safety Goals compliance, tracer findings, environmental survey findings, mock survey outcomes, TJC monitoring requirements for post survey, sentinel event alert progress reports; formulates actions, responses and plans to address accreditation agency measures of success, complaints, and compliance issues; revises the National Patient Safety Goals poster, distributes to the departments and educates staff on the impact of the goals on safe patient care; conducts chart review; attends safety huddles; assists the organization in identifying opportunities for improvement; originates and implements a tri-annual survey readiness plan and tlmeline aimed to engage staff in a robust culture of compliance for all areas assigned to the Hospital CCH Number; constructs tracer assessment tools for patient throughput, system and process tracers to assess standards of care and change processes that constitute quality outcomes; identifies and facilitates change processes using Robust Process Improvement (RPI) to uncover specific causes of failure and utilize the Plan, Do, Study, Act (PDSA) Performance Improvement model to direct Improvement efforts; researches and stays abreast of news releases, compliance changes and TJC standards under review for the circulation to leadership, management, staff and physicians on a regular basis; serves as a member of various committees as directed such as: Environment of Care, PI Council and ad hoc committee as needed; maximizes internet, intranet, email, databases, spreadsheets, word processing and presentation programs to advance survey readiness; facilitates completion of the annual Intra-Cycle Monitoring (ICM) process by initiating departmental analyses teams to assess departmental compliance with all elements of standard compliance; acts as facilitator and participates in the environmental rounding with department heads to identify and prioritize high risk, high volume areas that require monitoring of environmental areas; establishes and leads performance improvement committees as needed to implement TJC standards revisions, CMS changes and/or new standards that result in change processes;
collaborates with the System Clinical Compliance Data Analyst to develop and implement processes to collect data that translate into reportable formats, meaningful graphs, and trend analyses with benchmarks to identify opportunities for improvement; presents data to leadership and committee for change improvement processes using the Plan, Do, Study, Act (PDSA) model; abides by and enforces all compliance requirements and policies and performs these responsibilities in an ethical manner consistent with the organization’s values; adheres to policies pertaining to confidentiality; performs under minimal supervision with accountability for specific goals/objectives; regular and prompt attendance; ability to work schedule as defined and additional hours as required; related duties as required.
Qualifications:
Associates degree from an accredited school of nursing or healthcare related program as approved and accepted by the University of South Alabama, three years of professional clinical hospital experience, and current licensure with the State of Alabama in clinical field of study. Experience with Joint Commission, DNV, and State survey preparation and continued readiness highly preferred

Please refer the Job description for details