Towson, Maryland, Job Description General Summary Under limited supervision, ensures organizational compliance with quality measures and other performance indicators required by regulatory and accrediting entities. Provides input into establishing goals, objectives and performance standards. Ensures compliance with policies, quality standards, Joint Commission, CMS and DHMH regulations and codes. Is responsible for the coordination of patient safety activities, and regulatory compliance activities The position encompasses various roles (e.g., coordinator, educator) and requires effective interpersonal and management skills to motivate staff. . In addition, the individual will assist with the management of the UMMC Event Reporting System, and will provide support to the Hospital's Performance Improvement Program. Duties include working with UMSJMC departments on risk reduction strategies to enhance patient safety and meet regulatory compliance. Provides the tools, techniques and skills necessary for patient safety, outcomes measurement, process improvement as well as thorough and credible root cause analysis processes. Works with leadership, staff and physicians to provide a planned, systematic, organization-wide approach to identify, measure, monitor, and evaluate patient safety and improvement activities. Helps develop and revise policies and procedures; interprets and ensures compliance with UMSJMC policies, quality standards, regulations and codes. Develops and maintains interactive and collaborative relationships with key medical staff. 2. Principal Responsibilities and Tasks The following statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all job duties performed by personnel so classified. The following statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all job duties performed by personnel so classified. MC Patient Safety and Regulatory Compliance Coordinator A. Provides leadership and/or assistance with hospital-wide activities to evaluate and improve adherence to the Joint Commission accreditation standards, CMS Conditions of Participation, and MD State regulations in preparation for all surveys. 1. Assists with preparation and participates in organizational visits from accrediting agencies. 2. Participates in survey command center activities which may include but is not limited to: keeping track of and fulfilling surveyor requests for environmental logs, policies and procedures, employee files, contracts, etc., responding to emails and phone calls. 3. Assists and participates in organization-wide Joint Commission readiness activities including tracers; monitoring and educating staff in regulatory compliance and hospital policy requirements. 4. Enters tracer data into accreditation tracking tool; reports from these data are provided to staff to use in staff education and improving compliance with Joint Commission standards and CMS Conditions of Participation (COPs). 5. Assists with internal regulatory assessments to evaluate and validate compliance with current standards set forth by various external regulatory agencies. 6. Abstracts data to evaluate medical center's compliance with Joint Commission standards and CMS Conditions of Participation (COPs). 7. Monitors action plan progress in response to external audits and surveys through concurrent and retrospective chart review. 8. Works with providers to monitor and promote quality improvement activities related to regulatory requirements and clinical documentation in the medical record. 9. Participates in Epic UDCs to assure documentation elements are properly embedded in the EHR to meet regulatory standards and conditions of participation. 10. May assist in State and Federal Quality projects to obtain comparative data on quality and regulatory indicators. 11. Attends hospital based committee meetings as assigned. B. Plans, organizes, and directs activities centered on hospital compliance with the Joint Commission, CMS and other external reporting entities. 1. Ensures compliance with established quality measures. 2. Assures data quality, reliability and validity; compiles and enters data into designated data base. 3. May serve as steward for the System to validate data submissions to the Joint Commission and CMS. 4. Abstracts data from EHR to evaluate medical center's compliance with the Joint Commission and CMS guidelines. 5. Analyzes data to identify opportunities for improving organization's performance. 6. Keeps staff up-to-date with on-going changes in documentation requirements.. 7. Provides regular feedback to staff and provides support as requested in quality & safety activities. 8. May facilitate development of department level quality initiatives. MC Patient Safety and Regulatory Compliance Coordinator 33. O. Assists the UMSJMC Patient Safety Officer with reporting to the State and The Joint Commission. A. P. Ensures compliance with Regulatory Requirements . Ensures compliance with external regulators and accrediting agencies (e.g., The Joint Commission, CMS, Maryland State Department of Health Office of Healthcare Quality (OHCQ). Ensures that Medical Center and department policies, procedures and standards meet requirements and regulations of regulatory and accrediting agencies related to patient safety. Other Tasks: 1. Travel to all University of Maryland Medical Center locations may be needed 2. Knowledge, Skills and Abilities A. Demonstrate expertise in the use of data, data validation and production of reports. B. Demonstrate the ability to effectively navigate computer applications for use in abstracting needed data. C. Demonstrates the ability to effectively navigate external databases which publicly report quality data and to retrieve and/or input data. D. Current and comprehensive knowledge of the methodology and definitions utilized for data abstraction for core measures is preferred. E. Highly effective oral and written communication skills are required to work with all levels of hospital personnel, administrators and clinical staff as well as outside agencies. F. Ability to work with limited supervision in the management of projects and programs is required. Initiative and problem-solving skills are needed. G. Ability to develop collaborative programs and projects with other disciplines is required. Must be able to contribute to team effectiveness, build relationships and facilitate improvements H. Self-motivated, independent thinker. I. Working knowledge of Microsoft word, excel and, power point Company Description When you come to the University of Maryland St. Joseph Medical Center, you're coming to more than simply a beautiful 37-acre, 218-bed suburban Baltimore, Maryland campus. You're embarking on a professional journey that encourages opportunities, values a team atmosphere, and makes convenience and flexibility a priority. Joining our team of healthcare professionals means you'll be contributing to a locally and nationally recognized institution. UM St. Joseph has been recognized by The Leapfrog Group as a grade 'A' hospital and by U.S. News & World Report as #3 in both the state and Baltimore Metro area, making UM St. Joseph the highest-ranking community hospital in Maryland. In addition, we've been consistently recognized as a top employer by Baltimore magazine. Qualifications Education and Experience A. BSN is required. Master's degree preferred. B. Licensure by the Maryland State Board of Nursing Examiners is required. C. Three (3) years nursing experience required. In addition, one to two (1-2) years of progressively responsible professional experience performing quality and/or regulatory compliance review or equivalent is required. D. Current experience in collecting and submitting externally reported quality data is preferred Additional Information All your information will be kept confidential according to EEO guidelines.