Job Overview:
Helps coordinate under the direction of the Director, Quality Data Management, the hospital s regulatory readiness processes to assure compliance with regulations and standards of regulatory and accreditation agencies
Qualifications:
Education:
Bachelor s degree in healthcare related field required; Master s degree preferred,
RN License in New Jersey desirable,
Professional Certification CPHQ or CPPS highly desirable,
Experience:
Minimum of five years experience in clinical practice,
Knowledgeable about state, federal, and regulatory agency requirements,
Personal Qualifications:
Ability to work effectively with colleagues, physicians and hospital staff,
Ability to effectively and efficiently organize, prioritize, and coordinate job responsibilities,
Outstanding verbal and written communication skills,
Strong leadership skills,
Essential Functions:
Supervisory Expectation
Helps coordinate under the direction of the Director, Quality Data Management, the hospital s regulatory readiness processes to assure compliance with regulations and standards of regulatory and accreditation agencies.
Monitors compliance of the standards and works in collaboration with the departments to implement performance improvement/regulatory initiatives.
Assists departments with development of performance improvement/regulatory indictors and analyzes the data collected.
Performs survey readiness tracers and provide feedback to the department for follow up
Assures that meetings are scheduled, agendas are prepared and minutes are completed in a timely manner.
Provides ongoing education regarding quality, regulatory and performance improvement initiatives at new employee and physicians orientation
Provides ongoing education regarding quality, regulatory and performance improvement initiatives house wide
Provides ongoing information and education on changes and updates to Joint Commission, CMS, and Department of Health standards and other agencies requirements.
Quality Reviews
Coordinates quality reviews and responses on NJDOH and Joint Commission patient complaints
Coordinates root cause analysis on reportable events outline in the New Jersey Patient Safety Act. Ensures action plans are implemented and monitoring is conducted.
Conducts one annual RCA on a near miss
Proactive Risk Assessment
Coordinates the required FMEA/RCA required by regulatory agencies
Policies and Procedures
Co-chairs the hospital policy and procedure committee and assists with maintaining the online policy and procedure system.
Assists with scheduling meetings, preparing agendas and minutes in a timely manner
Online Event Reporting System
Reviews reported events for potentially meeting reporting requirements for the Patient Safety Reporting System. .
Verge
Reviews all events reported with in the their departmental responsibilities
Assist departments with implementation of action plans
Completes special projects of the VP Patient Safety/Quality in a professional manner, as evidenced by the following:
Project is completed according to the established guidelines and time frames of the requesting party.
Effective time management skills are used to ensure that projects are completed without jeopardizing normal daily work requirements.
Careful research and investigation is done so that data being used are accurate and up to date.
Pursues ongoing professional growth and development as evidence by the following:
Attendance at seminars, workshops, conferences, in-services.
Review and sharing of literature.
Networking with colleagues.
Environment of Care Standard:
Demonstrates the awareness of safety, security, life safety, emergency preparedness and utility and equipment management policies competencies.
Adheres to Standard Precautions
Adheres to Safety and Infection Control policies
Attends mandatory in-services
Helps maintain a safe and clean patient/work environment
Follows incident reporting procedures
Ensures that appropriate standards of practice follow corporate compliance guidelines, and that results of accreditation surveys and licensure reviews by NJSDOH and JCAHO are satisfactory.
Acts in an ethical and legal manner, and assures that all actions are in the best interest of both patients and the hospital.
At RWJBarnabas Health, our market-competitive Total Rewards package provides comprehensive benefits and resources to support our employees physical, emotional, social, and financial health.
Paid Time Off (PTO)
Medical and Prescription Drug Insurance
Dental and Vision Insurance
Retirement Plans
Short & Long Term Disability
Life & Accidental Death Insurance
Tuition Reimbursement
Health Care/Dependent Care Flexible Spending Accounts
Wellness Programs
Voluntary Benefits (e.g., Pet Insurance)
Discounts Through our Partners such as NJ Devils, NJ PAC, Verizon, and more!
Choosing RWJBarnabas Health
RWJBarnabas Health is the premier health care destination providing patient-centered, high-quality academic medicine in a compassionate and equitable manner, while delivering a best-in-class work experience to every member of the team. We honor and appreciate the privilege of creating and sustaining healthier communities, one person and one community at a time. As the leading academic health system in New Jersey, we advance innovative strategies in high-quality patient care, education, and research to address both the clinical and social determinants of health.
RWJBarnabas Health aims to truly make a unique impact in local communities throughout New Jersey. From vastly improving the health of local residents to creating educational and career opportunities, this combination greatly benefits the state. We understand the growing and evolving needs of residents in New Jersey whether that be enhancing the coordination for treating complex health conditions or improving community health through local programs and education.
Equal Opportunity Employer
RWJBarnabas Health is an Equal Opportunity Employer
