Risk Management & Regulatory Compliance Coordinator AdventHealth Deland

• Serves as a hospital content expert on performance improvement projects, accreditation and safety.
• Provides leadership and support regarding questions from staff, leaders and physicians on performance improvement, quality projects, regulatory and accreditation. Utilizes outside resources for complex questions to ensure correct communication and interpretation (i.e. TJC intranet, ECRI, QualityNet websites).
• Participates in collaboration with or as the designee for the Quality Director, on AHS quality initiatives and/or collaboratives. This may include but is not limited to: Glycemic management, Partnership for Patients/HIIN, AHRQ safety indicators as assigned. Assists with data management, performance improvement, medical record review and meeting organization to help ensure initiative success and goals are met. Utilizes appropriate PowerInsight (PI) reports to coordinate performance improvement and safety projects.
• This position represents the Office of Clinical Effectiveness at medical staff committees, performance review councils, and hospital leadership meetings by providing regulatory, quality and safety updates as assigned. 
• Responsible for maintaining daily screening process for all inpatient admission throughout hospital. Utilizes appropriate PI reports as verification tool to ensure all patients with coded diagnosis for core measure conditions after discharge have all appropriate safety measures addressed.
• Plans, implements & monitors interventions to ensure evidence-based practices are implemented and participates in and/or leads performance improvement committees and teams.
• Prepares reports and statistical analysis for medical staff and hospital leadership meetings.  Routinely utilizes sensitivity and diplomacy in daily interactions with others as many deal with sensitive, confidential or controversial information. 
• Patient safety and/or risk management designee when Quality Director and Risk Manager are out of the hospital or need additional support. Complete and analyze quality event timelines, root cause analysis timelines, review core measure cases, review risk events, notify regulatory bodies of any Code 15 or other reportable events, and identify care variation in case reviews. 
• Responsible for all incoming and outgoing sensitive regulatory correspondence, ensuring appropriate follow-up, including drafting of response correspondence. 
• Provides analysis of provider-specific and Quality Advisor reports from the Premier database and produces recommendations for performance improvement projects to hospital leadership.
• Assists Quality Director and/or Quality Manager, as assigned, to help with quality and safety initiatives throughout the year. Performs other duties as assigned. This includes, but is not limited to, maintaining department files in compliance with regulatory guidelines and maintain intranet for accreditation, patient safety, and performance improvement.

KNOWLEDGE AND SKILLS REQUIRED:

• Strong computer skills in Microsoft Office Suite (i.e., Word, Excel, Access, PowerPoint, Outlook)
• Excellent communication skills- written, oral and presentation - to build relationships with all departments, physicians and executive team
• Must possess presentation skills, as well as negotiation and advocacy skills when interacting with fellow members of the healthcare team as well as outside accrediting agencies, legal bodies, and other healthcare institutions. Internal and external contacts are often problem-driven
• Analytical ability to interpret data trends
• Acts independently and demonstrates organizational and problem-solving skills
• Facilitation of various PI methodologies (Six Sigma, Lean, PDSA, etc.) PREFERRED

EDUCATION AND EXPERIENCE REQUIRED:

• Bachelorâ™s degree OR 5 yearsâ™ clinical experience
• Minimum of 3 years healthcare experience
• Preparing and presenting professional presentations to executive leadership teams
• Accreditation activities and survey preparation
• Provider performance improvement activities

EDUCATION AND EXPERIENCE PREFERRED:

• Bachelorâ™s degree in a healthcare related field
• Experience with regulatory, patient safety, Peer Review or OPPE process
• Healthcare related performance improvement or project management experience
• Proven ability in areas of leadership/ supervision, knowledge of regulatory aspects of healthcare, QA/QI principles, education and outcomes

LICENSURE, CERTIFICATION OR REGISTRATION PREFERRED:

• Six Sigma Performance Improvement Certification
• LEAN Performance Improvement Certification
• Team STEPPS Certification
• Certified Professional in Healthcare Risk Management (CPHRM)
• Certified Professional in Patient Safety (CPPS)
• Certified Joint Commission Professional (CJCP)
• Certified Professional in Healthcare Quality (CPHQ)

The Risk Management & Regulatory Compliance Coordinator provides leadership for safety, accreditation and regulatory activities through relationship with hospital administration and leadership, medical staff leadership, physicians, nurses, and ancillary and allied health departments to improve knowledge and performance for hospital safety, performance improvement and quality initiatives. Assists in the oversight of department staff as directed by the Director and/or Quality Manager. Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all. Provides concurrent case reviews and recommendations to ensure that evidence based best practices are implemented timely.  Responsible for independent coordination of program submissions in compliance with federal guidelines. Liaison for the medical staff physician Medical Review and OPPE/FPPE process. This position represents the Office of Clinical Effectiveness at medical staff committees, new hire orientation and hospital leadership meetings by providing accreditation, regulatory, quality and safety updates. Coordinates annual accreditation activities. Serves as the patient safety designee as needed. Responsible for planning, implementation & monitoring of interventions to ensure evidence-based practices are implemented and participates in and/or leads performance improvement committees as directed.  Prepares reports and statistical analysis for medical staff and hospital leadership meetings.  Routinely utilizes sensitivity and diplomacy in daily interactions with others as many deal with sensitive, confidential or controversial information. Adheres to and enforces the Florida Hospital Corporate Compliance Plan, the rules and regulations of all applicable local, state, and federal agencies, and the standards of applicable accrediting bodies.  Ensures facilitation of the patient grievance process as required by state and federal statutes. Adheres to and enforces the Florida Hospital Corporate Compliance Plan, the rules and regulations of all applicable local, state, and federal agencies, and the standards of applicable accrediting bodies.