About this role
Job Requirements
Shift: Mon-Fri 7.30am-3.30pm
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 UMMC policies, quality standards, Joint Commission, CMS and DHMH regulations and codes.
Responsibilities and Tasks
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.
- Assists with preparation and participates in organizational visits from accrediting agencies.
- 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.
- Assists and participates in organization-wide Joint Commission readiness activities including tracers; monitoring and educating staff in regulatory compliance and hospital policy requirements.
- 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).
- Assists with internal regulatory assessments to evaluate and validate compliance with current standards set forth by various external regulatory agencies.
- Abstracts data to evaluate medical center’s compliance with Joint Commission standards and CMS Conditions of Participation (COPs).
- Monitors action plan progress in response to external audits and surveys through concurrent and retrospective chart review.
- Works with providers to monitor and promote quality improvement activities related to regulatory requirements and clinical documentation in the medical record.
- Participates in Epic UDCs to assure documentation elements are properly embedded in the EHR to meet regulatory standards and conditions of participation.
- May assist in State and Federal Quality projects to obtain comparative data on quality and regulatory indicators.
- 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.
- Ensures compliance with established quality measures.
- Assures data quality, reliability and validity; compiles and enters data into designated data base.
- May serve as steward for the System to validate data submissions to the Joint Commission and CMS.
- Abstracts data from EHR to evaluate medical center’s compliance with the Joint Commission and CMS guidelines.
- Analyzes data to identify opportunities for improving organization’s performance.
- Keeps staff up-to-date with on-going changes in documentation requirements.
- Provides regular feedback to staff and provides support as requested in quality & safety activities.
- May facilitate development of department level quality initiatives.
Work Experience
Education and Experience
- Associate’s Degree in Nursing is required. BSN preferred.
- Licensure by the Maryland State Board of Nursing Examiners is required.
- 3 years nursing experience required; regulatory, patient safety, or quality focus is preferred.
- Current experience in collecting and submitting externally reported quality data is preferred.
Knowledge, Skills and Abilities
- Demonstrate expertise in the use of data, data validation and production of reports.
- Demonstrate the ability to effectively navigate computer applications for use in abstracting needed data.
- Demonstrates the ability to effectively navigate external databases which publicly report quality data and to retrieve and/or input data.
- Current and comprehensive knowledge of the methodology and definitions utilized for data abstraction for core measures is preferred.
- 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.
- Self-motivated, independent thinker.
- Working knowledge of Microsoft word, excel and, power point
Patient Safety
Ensures patient safety in the performance of job functions and through participation in hospital, department or unit- based patient safety initiatives.
- Takes action to correct observed risks to patient safety.
- Reports adverse events and near misses to appropriate management authority.
- Identifies possible risks in processes, procedures, devices and communicates the same to those in charge.