Rn Policy And Procedure Coordinator

Responsible for collaborating with leadership to prepare the organization with ongoing programs to promote continuous accreditation readiness, clinical compliance, and patient safety improvement for assigned facility(s).

Assist leadership in defining key performance indicators and developing measurement tools to evaluate accreditation and patient safety process improvements; coordinates patient safety culture assessment efforts
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Assists with coordination of accreditation and patient safety readiness meetings, discusses barriers to continual readiness, changes in regulations, develops action plans, measures sustainability and reassesses approach to maximize success
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Collaborates with leadership to complete required regulatory reports to include investigating and developing an improvement response plan for regulatory complaints and sentinel events.
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Facilitates tracers, medical record reviews, and environmental assessments, compiles and distributes compliance reports to departments, as well as facility and system oversight teams. -
Guides and coaches leaders and frontline staff in the development of accreditation and patient safety improvement initiatives; provides direction to department and facility leadership in the planning of a systematic, organization-wide approach to continuous accreditation readiness and patient safety improvement opportunities. -
Maintains open communication and a close working relationship with facility leadership to optimize patient safety culture and to support a constant state of readiness for accreditation reviews
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Serves as a subject matter expert, addressing all aspects of pre-survey, survey and post-survey activity including the planning and execution of The Joint Commission annual intracycle reviews.
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Utilizes facilitation skills with proactive risk assessments, and other patient safety process reviews to include assistance with root cause analysis for breakdowns.
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Required:
Graduate of RN Educational Program with BSN or BSN in progress to be completed within 4 years. Bachelor's degree in Medical Technology or other health related field is acceptable.
Preferred:
Master's Degree in Nursing or Business Administration

Required:
At least 3 years' experience in acute healthcare setting. Experience in data analysis.
Preferred:
Previous experience with regulatory compliance

REQUIRED
Required;
Registered Nurse with current NC license
Preferred:
Quality, Accreditation or Patient Safety Certification
PREFERRED