Senior Quality, Safety, PFR & Compliance Specialist - East Sandwich - ( 3274349 )

　　Description

　　Lead and perform day-to-day activities related to performance improvement, patient safety, risk management, patient experience, and hospital accreditation. Regulatory compliance activities include audits and investigations, developing and shepherding action plans, and conducting related educational programs.

　　Safety occurrence reporting system and case analysis related to adverse events are managed per department and regulatory guidelines.

　　Patient and Family Relations program is implemented and monitored to achieve stated goals.

　　Responsible for incoming calls, visits, and correspondence to serve as a liaison between patients, loved ones, and staff in acknowledging and responding to feedback (complaints/grievances/compliments) and other requests in a compassionate and supportive manner. Utilizes data management system to meet regulatory requirements for CMS, DPH, and The Joint Commission for complaint management and resolution process.

　　Performance improvement and patient safety activities implemented to address quality concerns identified through hospital systems or by external reviewers to meet expected outcomes.

　　Accreditation survey preparation and coordination is provided to ensure regulatory compliance.

　　Facilitate completion of required evidence of standards compliance action plans following survey activity.

　　Chair and/or participate in quality-related committees to ensure safe patient care and exceptional patient experience.

　　Staff education is provided to build organizational capability.

　　Special projects and counsel are provided to department managers as needed to maintain compliance with organization and regulatory standards.

　　Potential quality or compliance concerns identified internally through hospital systems or by external reviewers (i.e., quality improvement organization, managed care providers, referring facilities) are evaluated via clinical chart review and data collection, with analysis of aggregate data and development of reports.

　　Additional department, organization, or network activities are completed per established objectives.

　　Implement Quality improvement work in both the hospital and skilled nursing facility setting per network goals.

　　Assist with completion of the annual Patient Care Assessments and submit to the BORM Quality and Patient Safety Division.

　　Because this role in an active change management environment, this specialist will need to demonstrate flexibility and open-mindedness as the contours of this position will actively evolve.

　　Qualifications

　　Education/Degree

　　Required

　　Bachelor’s degree in nursing, therapy or another clinical field required.Preferred

　　Education and/or experience with both hospital and long-term care settings.Experience

　　Required

　　Minimum of two years' experience with quality, safety and compliance in a healthcare setting.

　　Experience with accreditation surveys such as Joint Commission and/or CARF.

　　Preferred

　　Three to five years related experience preferred.Licensure/Certification

　　Required

　　Current Massachusetts license as Registered Nurse or other health care professional required.Preferred

　　Certificated Professional in Healthcare Quality, Certified Professional in Healthcare Risk Management.Skills (Specific learned activity gained through training (e.g. computer skills, keyboarding, presentation, CPR, ACLS, etc.)

　　Required

　　Computer proficiency required. Microsoft office applications preferred with ability to learn new software.Preferred

　　Ability to analyze data and make recommendations for improvement.

　　Ability to create PowerPoint presentations and present to a variety of audiences.

　　Highly developed communications and interpersonal skills, working with diverse population.

　　Work independently, be self-directed and contribute as a member of a team.

　　Anticipates challenges and develops and implements strategies for addressing them.

　　High level of service delivery. Demonstrate initiative with ability to prioritize work, meet deadlines and adapt to changing situations.

　　Attention to detail.

　　EEO Statement:

　　Spaulding Rehabilitation Network (SRN) is committed to diversity in the workplace which begins with respect and opportunity for all. SRN takes affirmative action to ensure that equal employment opportunity is provided to all persons regardless of race, religious creed, color, national origin, sex, sexual orientation, gender identity, genetic information, age, ancestry, veteran status, disability or any other basis that would be inconsistent with any applicable ordinance or law. If you need a reasonable accommodation in coming to or participating in the interview process, please let us know.

　　Primary Location : MA-East Sandwich-SCC Spaulding Cape Cod

　　Work Locations :

　　SCC Spaulding Cape Cod

　　311 Service Road

　　East Sandwich 02537

　　Job : Professional/Managerial

　　Organization : Spaulding Hospital Cape Cod(SRN and SCC)

　　Schedule : Full-time

　　Standard Hours: : 40

　　Shift : Day Job

　　Employee Status : Regular

　　Recruiting Department: : SCC Administration

　　Job Posting : Jan 22, 2024

　　Req ID: 3274349