GENERAL SUMMARY OF POSITION

Serves as a resource that supports a regulatory compliant organization, works with leaders and teams across MGUH to support selected high priority clinical, regulatory, patient safety, quality or high reliability projects and programs identified by senior leadership. Supports sustainability and a culture of continuous readiness and improvement through ongoing collaboration and engagement with key stakeholders. Serves as subject matter expert on regulatory/accreditation requirements and leads organization-wide efforts to maintain compliance. This individual assists in the review of clinical area/activities for regulatory compliance. Activities are coordinated with the AVP, Regulatory Readiness and are performed in accordance with all applicable laws and regulations and MedStar philosophy, policies, procedures and standards

EDUCATION

• Bachelor’s degree Nursing or clinical field required or
• Master’s degree preferably in Nursing, Healthcare Administration, or related field. preferred

EXPERIENCE

• 3-4 years Clinical experience in acute care/ ambulatory required and
• 3-4 years In accreditation coordination for hospital and specialty accreditations preferred
• Experience in quality or performance improvement, staff development and/or risk management. preferred

KNOWLEDGE, SKILLS, AND ABILITIES

• Ability to read, write, speak, and comprehend English.
• Proficient Computer skills
• Knowledge in facilitating teams and use of statistical tools i.e. Radar Charts, Control Charts, Scatter Diagrams, etc.
• HIPAA policies on Confidentiality
  This position has a hiring range of $87,318 - $157,289

• Policy and Procedure Program Development: Advises on Policies & Procedures from Medstar corporate by triaging new policies and clinical guidelines for adoption or alignment. Ensures appropriate review and approval.
• Policy and Procedure Program Development: Leads ongoing skill building of department/division Policy and Procedure Owners in best practices for Policy and Procedure development and implementation coordination.
• Policy and Procedure Program Development: Leads Policy and Procedure Program Development. Serves as internal mentor to departments and/or committees to strengthen their policies & procedures, clinical practice guidelines, charters, scopes of service or other guiding documents including utilization of the document flow process.
• Patient Safety & Quality: Collaborates with Center for Patient safety and Quality on serious safety events, internal regulatory readiness reports, actual survey and accreditation reports, and reports reportable events to the Department of Health.
• Patient Safety & Quality: Develops, leads tracers and engages with PI teams to dive deeper into clinical operations using the tracer methodology to identify best practices, trends, areas for improvement and monitor planned change.
• Patient Safety & Quality: Leads hospital-wide performance improvement teams to meet regulatory body requirements. Compile, analyze, and communicates data from audits and assist leaders to develop, implement, and sustain solutions to maintain compliance for corrective action plans.
• Regulatory Readiness: Participates in the development of responses to the requests, inquires, and survey comments from inspectors/surveyors of accrediting bodies such as The Joint Commission and DC Department of Health.
• Regulatory Readiness: Prepares hospital applications for The Joint Commission, District of Columbia Hospital License, and Centers for Medicare and Medicaid Mental Health.
• Regulatory Readiness: Demonstrates the ability to lead The Joint Commission, Department of Health and other regulating agency surveys including the College of American Pathologists and the Center for Medicare and Medicaid Services surveys including all internal and regulatory corrective action items/plans.
• Regulatory Readiness: Performs regulatory-required contract vendor oversight monitoring activities.
• Compliance Support: Ensures compliance with Joint Commission standards and DSC Stroke Standards and leads and coordinates hospital-wide Joint Commission preparation and on-going compliance.
• Regulatory Readiness: Demonstrates knowledge of state and federal regulations, Joint Commission standards/process and other performance improvement concepts in keeping with the standard of care.
• Regulatory Readiness: Educates staff on compliance issues and oversees follow-up. Stays abreast and serves as subject matter expert on state and federal regulatory regulations. Ensure policies and procedures are aligned with regulatory standards.
• Regulatory Readiness: Collaborates with Education Leads for Nursing, Pharmacy, Medical Staff, informatics, and others on key organizational priority regulatory projects to ensure appropriate training is available to staff.
• Regulatory Readiness: Creates communication and supportive documents to keep leaders abreast of the Regulatory Readiness program.
• Regulatory Readiness: Conducts regular readiness tracer activities in partnership with other internal subject matter experts such as infection prevention, pharmacy, nursing and report findings to appropriate leaders.
• Regulatory Readiness: Conducts periodic medical record documentation compliance reviews and reports findings to appropriate leaders. Remains up to date with current regulatory, accreditation and license standards.
• Regulatory Readiness: Leads the effective use of JCR software, collaborates and coordinates regulatory activities.