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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.

Oakwood, Georgia, Job Category: Executive Leadership, Nursing - Registered Nurse Work Shift/Schedule: Varies Northeast Georgia Health System is rooted in a foundation of improving the health of our communities. About the Role: Job Summary The Director of Patient Safety will work collaboratively with the Chief of Operational Excellence and the Medical Director of Patient Safety to advance a patient safety program that promotes a culture of safety and the elimination of preventable harm for the entities of Northeast Georgia Health System. This position provides leadership in developing a culture of safety and in identifying opportunities and initiatives to enhance patient safety for the hospitals in the system. This will include monitoring and distribution of patient safety metrics and other key data, providing data review and analysis, and partnering with hospital leadership to align data with the strategic plan. A primary focus of the position will be oversight of the comprehensive patient safety program, to include patient safety event management, root cause analysis and facilitation of effective, timely action plans. He/She shall be responsible, in conjunction with the Chief of Operational Excellence and the Medical Director of Patient Safety, for ensuring that the requirements of a High Reliability Organization are determined, implemented, and maintained for Northeast Georgia Health System. Minimum Job Qualifications Licensure or other certifications: Current, unrestricted license to practice in GA (GA licensure or multi-state [compact] license). Educational Requirements: Bachelors Degree. Minimum Experience: Minimum of five (5) years of progressively responsible experience in a hospital environment, including experience in management and experience working in patient safety and performance improvement/quality. Other: Preferred Job Qualifications Preferred Licensure or other certifications: Preferred Educational Requirements: Master Healthcare Administration, Business Administration or Organization Leadership. Preferred Experience: Other: Job Specific and Unique Knowledge, Skills and Abilities Strong written and verbal communication skills Strong organizational skills Excellent interpersonal and facilitation skills Knowledge of patient safety and high reliability organization principles, theory, and methods. Knowledge of and experience with patient safety analysis techniques (methods), including root cause analysis, cause and effect analysis, and failure mode and effect analysis Essential Tasks and Responsibilities Maintains oversight and responsibility for the patient safety programs for all NGHS entities. With the Medical Director, serves as a subject matter expert for patient safety, maintaining an active understanding of current thinking and innovative programs regarding patient safety both locally and nationally. Monitors CMS, QHIP, NDNQI, and Leapfrog data and trends and all applicable state and federal requirements. Clearly defines patient safety, including the behavioral changes necessary to achieve cultural transformation to enable NGHS to become a high reliability organization. Develops and deploys real-time and trended patient safety reports intended to target a specific audience (department, practice, or unit). Oversees the extraction of data from the electronic health record and other data sources as necessary. Identifies and presents key issues impacting patient safety for Senior Leadership discussion and decision making, which will include findings, barriers to success, and progress toward results. Assesses and makes recommendations to appropriate committees and task forces of any changes needed. Documents and communicates throughout NGHS the shared vision for patient safety improvements. Develops the framework and protocols in which all patient safety initiatives will be deployed. Consistently measures results. In coordination with Organizational Development, oversees the development of training for leaders, physicians, and staff in best practices for patient safety. Oversees the management and use of event information to benchmark and track progress to zero preventable harm for all NGHS entities. Encourages utilization of PMDG for NGHS entities. Promotes and supports professional growth and development of staff, and facilitates participation in PSO learning collaboratives. Provides outstanding service to all customers, fosters teamwork, and practices fiscal responsibility. Hires, disciplines, trains, and develops staff; conducts performance evaluations for assigned staff. Develops and monitors the operating budget for the patient safety department. Develops, initiates, maintains, and revises policies for the general operation of the Patient Safety department. Physical Demands Weight Lifted: Up to 20 lbs, Occasionally 0-30% of time Weight Carried: Up to 20 lbs, Occasionally 0-30% of time Vision: Moderate, Constantly 66-100% of time Kneeling/Stooping/Bending: Occasionally 0-30% Standing/Walking: Occasionally 0-30% Pushing/Pulling: Occasionally 0-30% Intensity of Work: Frequently 31-65% Job Requires: Reading, Writing, Reasoning, Talking, Keyboarding Working at NGHS means being part of something special: a team invested in you as a person, an employee, and in helping you reach your goals. NGHS: Opportunities start here. Northeast Georgia Health System is an Equal Opportunity Employer and will not tolerate discrimination in employment on the basis of race, color, age, sex, sexual orientation, gender identity or expression, religion, disability, ethnicity, national origin, marital status, protected veteran status, genetic information, or any other legally protected classification or status.

Meridian, Idaho, Overview St. Luke's Health System in Meridian, ID is seeking an Accreditation Specialist to join our Quality & Patient Safety team. Unit/Position Summary Under direct supervision, the Accreditation Specialist, RN implements patient safety programs. Responsibilities Acts as the primary resource for assigned departments/sites for services related to the relevant regulatory program. Conducts and coordinates accreditation/regulatory standards based audits. Assesses accreditation findings or risks, facilitates analysis, and recommends interventions; tracks and evaluates action plans in response to accreditation findings Supports implementation of system accreditation programs, in collaboration with stakeholders; documents and prepares reports for distribution to stakeholders. Assists in the development and presentation of educational accreditation programs. Applies accreditation standards and survey methodology to moderately complex issues and problems; escalates more complex issues to department leadership. Possesses and applies novice/advanced beginner working knowledge of subject matter; decision making is limited in independence, based on standard rules and requires oversight; with mentoring, leads small teams that are limited to one to three departments in size. Utilizes the nursing practice, skills, concepts and/or methodologies to address accreditation opportunities. Advocates for evidence-based practice care standards and supports adoption of evidence-based practices and innovations. Performs other duties and responsibilities as assigned. Qualifications Education: ASN or BSN Experience: 2 years additional relevant experience. Licenses/Certifications: Current RN license in state of practice. or Education: Bachelor's Degree or 4 years of relevant experience in lieu of Degree Experience: 0 years Licenses/Certifications: None What's in it for you At St. Luke's, caring for people in the communities we serve is our mission - and this includes our own SLHS team. We offer a robust benefits package to support our teams both professionally and personally. In addition to a competitive salary and retirement plans, we ensure our team feels supported in their benefits beyond the typical medical, dental, and vision offerings. We care about you and have fantastic financial and physical wellness options, such as: on-site massages, on-site counseling via our Employee Assistance Program, access to the Virgin Pulse Wellness tool, as well as other formal training and career development offerings to ensure you are meeting your career goals. St. Luke's is an equal opportunity employer and does not discriminate against any person on the basis of race, religion, color, gender, gender identity, sexual orientation, age, national origin, disability, veteran status, or any other status or condition protected by law. *Please note: this posting is not reflective of all job duties and responsibilities and is intended to provide an overview to job seekers.

Springfield, Massachusetts, Baystate Health’s Clinical Risk Managers are an integral member of the healthcare team. As the Risk Manager, you will be responsible for identifying potential losses to the organization, both clinical and enterprise, developing and maintaining appropriate loss prevention policy and strategy.  The primary function of the Clinical Risk Manager will be to work with clinicians and administrators within the healthcare system to conduct proactive risk assessments, to review and investigate occurrence reports, adverse and sentinel events, and patient care complications and to identify patient safety issues, potential liability concerns and systems breakdowns. Serve as an expert resource regarding medicolegal issues, interpretation of state and federal statutes and regulation and potential legal and safety risks and ramifications of healthcare decisions and actions. Collaborate with the Patient Safety department in the identification and investigation of patient adverse events. Coordinate the Patient Safety CARe process: including investigation of patient safety adverse events, preparing providers to do disclosure of investigation results to patients and families and collaborating with our Captive Insurer to work toward resolution. Collaboration with providers to promote patient safety. Prepare and submit mandated reports to state and federal agencies and, when applicable, coordinate with external agency investigations. Develop and present educational programs to medical, professional and technical staff on issues of professional liability and clinical and enterprise risk awareness and mitigation. Develop policies to ensure compliance with state and federal healthcare laws and regulations. Collaborate with Legal, Compliance, HR, Security and Patient Relations on risk events to ensure multidisciplinary review and management of case. Work with retained counsel on matters of investigation, discovery and trial preparation of lawsuits. Serve on committees throughout the Baystate Health organization to promote the health of our communities with quality and compassion. Requirements Bachelor’s Degree required, Masters preferred 5 or more years’ experience in a hospital setting in a clinical or administrative role with specific experience in dealing with patient safety, risk management, and /or quality. Excellent oral, and interpersonal written communication skills, poise in teaching and consulting Nursing experience strongly preferred. Previous healthcare risk management, safety, quality, professional liability experience preferred. Associate in Risk Management (ARM) and/or Certified Professional Healthcare Risk Management (CPHRM) certifications preferred Strong computer, writing, presentation and analytical research skills Other Information Ability to work a hybrid schedule available after initial training which includes working on site 3 days a week.   For more information, please email Donna.novak@baystatehealth.org or visit us online at: baystatehealthjobs.com and apply to Job ID# R29846 or interact with us socially at facebook.com/BaystateCareers or on Twitter @BaystateCareers. You Belong at Baystate At Baystate Health we know that treating one another with dignity and equity is what elevates respect for our patients and staff. It makes us not just an organization, but also a community where you belong. It is how we advance the care and enhance the lives of all people. DIVERSE TEAMS. DIVERSE PATIENTS. DIVERSE LOCATIONS. Baystate Health is an Equal Opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, marital status, national origin, ancestry, age, genetic information, disability, or protected veteran status.

Denver, Colorado, Please attach a copy of your resume, license/certifications to your application—thank you! All the benefits and perks you need for you and your family: Benefits from Day One  Paid Days Off from Day One  Student Loan Repayment Program  Career Development   Whole Person Wellbeing Resources Our promise to you: Joining AdventHealth is about being part of something bigger. It’s about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind, and spirit. AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding that  together  we are even better. Schedule:     PRN Shift : Days Location:  2525 S DOWNING ST, Denver, 80210   The role you’ll contribute:  Responsible for assessment of clients in consultation and cooperation with emergency department personnel, psychiatrists, clinicians, attending physicians and managed care representatives. Provides recommendation for disposition. The Crisis Assessment Specialist may perform the following as required: face-to-face evaluations, telephone triage evaluations, respond to and/or triage patient/family complaints, assist in management of all assessment records, perform statistical analysis, and perform billing-related activities connected with assessments. The value you’ll bring to the team:  Provides quality and timely assessment and referral services incorporating diagnostic skills and state specific regulations. Develops and offers safe and clinically appropriate disposition recommendations to psychiatrists, emergency department physicians, attending physicians within hospital, other mental health clinicians, managed care representatives and clients. May conduct after-hours crisis counseling for referred clients. Serves as primary communication liaison between clients, family members, emergency department staff, physicians, managed care representatives and behavioral healthcare personnel. Qualifications The expertise and experiences you’ll need to succeed: Education: Master’s degree in counseling, Social Work, Nursing, or related behavioral health field Experience: Three years direct behavioral clinical experience in an inpatient, outpatient, emergency, or residential treatment facility or setting Current Colorado State License in one of the following disciplines: Clinical Psychologist (PSY), Licensed Clinical Social Worker (LCSW), Licensed Professional Counselor (LPC), Licensed Marriage and Family Therapist (LMFT), Psychiatric Clinical Nurse Specialist (RN CNS), or Psychiatric Nurse Practitioner (RN NP) This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances. The salary range reflects the anticipated base pay range for this position. Individual compensation is determined based on skills, experience and other relevant factors within this pay range. The minimums and maximums for each position may vary based on geographical location.