Patient Safety and Regulatory Compliance Coordinator

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.Job DescriptionGeneral SummaryUnder limited supervision, ensures organizational compliance with quality measures and otherperformance indicators required by regulatory and accrediting entities. Provides input intoestablishing goals, objectives and performance standards. Ensures compliance with policies, qualitystandards, Joint Commission, CMS and DHMH regulations and codes.Is responsible for the coordination of patient safety activities, and regulatory compliance activitiesThe position encompasses various roles (e.g., coordinator, educator) and requires effectiveinterpersonal and management skills to motivate staff. . In addition, the individual will assist with themanagement of the UMMC Event Reporting System, and will provide support to the Hospital'sPerformance Improvement Program. Duties include working with UMSJMC departments on riskreduction strategies to enhance patient safety and meet regulatory compliance.Provides the tools, techniques and skills necessary for patient safety, outcomes measurement, processimprovement 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 revisepolicies and procedures; interprets and ensures compliance with UMSJMC policies, quality standards,regulations and codes. Develops and maintains interactive and collaborative relationships with keymedical staff.2. Principal Responsibilities and TasksThe following statements are intended to describe the general nature and level of work beingperformed by people assigned to this classification. They are not to be construed as an exhaustive listof all job duties performed by personnel so classified.The following statements are intended to describe the general nature and level of work beingperformed by people assigned to this classification. They are not to be construed as an exhaustive listof all job duties performed by personnel so classified.MC Patient Safety and Regulatory Compliance CoordinatorA. Provides leadership andor assistance with hospital-wide activities to evaluate and improveadherence to the Joint Commission accreditation standards, CMS Conditions of Participation, andMD 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 andprocedures, employee files, contracts, etc., responding to emails and phone calls.3. Assists and participates in organization-wide Joint Commission readiness activities includingtracers; monitoring and educating staff in regulatory compliance and hospital policyrequirements.4. Enters tracer data into accreditation tracking tool; reports from these data are provided to staffto use in staff education and improving compliance with Joint Commission standards andCMS Conditions of Participation (COPs).5. Assists with internal regulatory assessments to evaluate and validate compliance with currentstandards set forth by various external regulatory agencies.6. Abstracts data to evaluate medical center's compliance with Joint Commission standards andCMS Conditions of Participation (COPs).7. Monitors action plan progress in response to external audits and surveys through concurrentand retrospective chart review.8. Works with providers to monitor and promote quality improvement activities related toregulatory requirements and clinical documentation in the medical record.9. Participates in Epic UDCs to assure documentation elements are properly embedded in theEHR to meet regulatory standards and conditions of participation.10. May assist in State and Federal Quality projects to obtain comparative data on quality andregulatory indicators.11. Attends hospital based committee meetings as assigned.B. Plans, organizes, and directs activities centered on hospital compliance with the JointCommission, 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 database.3. May serve as steward for the System to validate data submissions to the Joint Commissionand CMS.4. Abstracts data from EHR to evaluate medical center's compliance with the Joint Commissionand 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 & safetyactivities.8. May facilitate development of department level quality initiatives.MC Patient Safety and Regulatory Compliance Coordinator33. O. Assists the UMSJMC Patient Safety Officer with reporting to the State and The JointCommission.A. P. Ensures compliance with Regulatory Requirements . Ensures compliance withexternal 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 standardsmeet requirements and regulations of regulatory and accrediting agencies relatedto patient safety.Other Tasks:1. Travel to all University of Maryland Medical Center locations may be needed2. Knowledge, Skills and AbilitiesA. 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 abstractingneeded data.C. Demonstrates the ability to effectively navigate external databases which publicly report qualitydata and to retrieve andor input data.D. Current and comprehensive knowledge of the methodology and definitions utilized for dataabstraction for core measures is preferred.E. Highly effective oral and written communication skills are required to work with all levels ofhospital 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 itiative and problem-solving skills are needed.G. Ability to develop collaborative programs and projects with other disciplines is required. Must beable to contribute to team effectiveness, build relationships and facilitate improvementsH. Self-motivated, independent thinker.I. Working knowledge of Microsoft word, excel and, power pointQualificationsEducation and ExperienceA. 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 ofprogressively responsible professional experience performing quality andor regulatorycompliance review or equivalent is required.D. Current experience in collecting and submitting externally reported quality data is preferredAdditional InformationAll your information will be kept confidential according to EEO guidelines.

Created: 2024-10-19