Location: Beverly, MA
Job ID: 170223-1A
Date Posted: Sep 29, 2021
Welcome to Beverly Hospital, part of Beth Israel Lahey Health. Beverly Hospital is a full service, community hospital providing leading-edge, patient-centered care to North Shore and Cape Ann residents. The hospital provides a full-range of state-of-the-art care and services including primary care, cardiovascular care, surgery, orthopedics, emergency care, maternity, pediatrics, as well as many other specialties. Beverly Hospital is nationally recognized for patient safety as it is one of only 42 hospitals in the United States to be awarded an “A” grade from The Leapfrog Group – the nation’s leading nonprofit watchdog on hospital quality and safety.
Beverly Hospital promotes the culture and philosophy which enables employees to give and receive the best of care. You can become a part of the team that achieves this success through our CREATE values of Community, Respect, Excellence, Accountability, Teamwork and Empathy.
About the Job
The Coordinator for Accreditation, Regulatory Compliance, and Patient Safety is responsible for developing and implementing a system for ongoing compliance with The Joint Commission (TJC) standards, Centers for Medicare and Medicaid Conditions of Participation, the Massachusetts Department of Public Health regulations and other regulatory agency requirements as assigned.
The Coordinator maintains awareness of and expertise in the TJC Standards, CMS Conditions of Participation, and state and federal health care regulations and the NHC’s status with compliance. The Coordinator develops a plan to rapidly adopt new and revised standards and requirements in a timely manner. The Coordinator ensures that departments throughout the organization comply with standards and requirements and that the hospital’s policies, procedures and practices accurately reflect the most current regulatory agency requirements and compliance.
The Coordinator is responsible for coordinating and leading the steering committee that oversees accreditation and compliance. The Coordinator provides support and assistance to The Joint Commission chapter leaders with regard to standards interpretation and implementation, identification of non-compliance and concerns, and coordination and implementation of corrective action plans. The Coordinator serves as the application manager of the E-dition, AMP (or other similar systems) and The Joint Commission secured extranet site. The Coordinator leads and coordinates mock patient and system tracers to gather compliance data, aggregates results and reports results and corrective action plans to the Accreditation Steering Committee. The Coordinator responds to and leads any announced or unannounced Joint Commission surveys, including command center management, assignment of survey teams/support, and coordinating surveyor needs. The coordinator, in conjunction with the Director of Performance Improvement, receives and responds to Joint Commission survey reports, including addressing clarifications. The Coordinator, in conjunction with the appropriate hospital leader develops and implements action plans following any findings (from internal tracers or formal survey reports). The Coordinator provides oversight of the organization’s data related any Joint Commission action plans. The Coordinator reports Joint Commission related results to the appropriate governance committees including Performance Improvement/Patient Safety Committee and Board of Trustee Quality Care Committee.
The Coordinator is responsible for oversight of compliance with federal and state standards and regulatory requirements and in the development of a comprehensive education and communication plan to educate the workforce, managers, directors, senior leaders and physicians about standards and changing requirements. The Coordinator serves as a resource to staff and physicians at NHC for matters related to accreditation and regulatory compliance. The Coordinator develops, presents, and/or coordinates the presentation of relevant and current education materials and programs related to accreditation and regulatory readiness.
The Coordinator responds to and leads any announced or unannounced state (DPH) or federal surveys (CMS), including command center management, assignment of survey teams/support, and coordinating surveyor needs. The Coordinator assists with other state or federal surveys as needed (including DMH or other licensing entities).
The Coordinator is responsible for developing corrective action plans following surveys in collaboration with the unit/department managers and reporting the results of the corrective action plan to the appropriate governance committees including Performance Improvement/Patient Safety Committee..
The Coordinator is also responsible for oversight of the organization’s patient safety reporting system and all related processes (currently RL Solutions “SafeSpot” patient safety reporting system) In this role, the Coordinator is an advocate for patient safety and works collaboratively with Risk Management to promote a culture of safety, identify patient safety improvement opportunities, conduct assessments, champion reporting of patient safety events and near misses and facilitate patient safety improvement.
Reporting Oversight and Leadership:
The Coordinator provides patient safety leadership and reporting oversight to the Nursing Quality Analyst. The Analyst reviews, analyzes, and trends patient safety reports. The Analyst serves on organization safety related committees, representing the Performance Improvement department, including the Falls Team, and Restraints Committee. The Analyst reports all activities and actions of their work to the Coordinator.
The Coordinator supervises any onsite regulatory related consultants hired by the PI department.
The Coordinator is involved with leading and strategic planning of the PI department under the Director and in conjunction with the Patient Experience Manager and the PI Manager.
The Coordinator may be assigned other roles or special projects at the discretion of the Director of Performance Improvement, including but not limited to Patient Safety, Lean related projects, Grant support, and/or emergency management drills/activities.
The Coordinator sits on organizational committees including Performance Improvement/Patient Safety, Safety Committee, Pharmacy & Therapeutics, Medication Safety Committee, NHC Leaders, and any other committee at the discretion of the Director of Performance Improvement
40 hour, exempt position, day shift.
Beth Israel Lahey Health is dedicated to improving health and wellness and making a difference in the lives of our patients, their families and all members of the communities we serve. Formed in March 2019, Beth Israel Lahey Health is a patient-centered, integrated care delivery system providing a continuum of services spanning academic, tertiary and community hospitals, dedicated orthopedic and psychiatric hospitals, primary and specialty care, community acute care, ambulatory care, behavioral services and home health. Beth Israel Lahey Health Performance Network is a unified joint contracting and population health management organization, jointly governed by participating physicians and hospitals.
Equal Opportunity Employer/Minorities/Females/Disabled/Veterans.
Bachelor’s Degree in nursing or health related field, Master’s Degree preferred. Minimum of five years of relevant experience in a health care environment with increasing responsibility. Experience with regulatory agencies and accreditation services strongly preferred. Certified Specialist in Healthcare Accreditation (CSHA) and/or Certified Professional in Healthcare Quality (CPHQ) preferred. Lean/Six Sigma certification or experience preferred. Proficient in Windows-based operating software and systems that include MS Word, MS Excel, MS Access and MS PowerPoint. Knowledge of clinical quality, patient safety and satisfaction performance measures and experience in project development, project management and strong analytical skills, including data entry, manipulation, management, and data analysis required. Excellent written and oral communication and presentation skills required.
Education & Experience: