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POSITION SUMMARY:

The Accreditation, Regulatory and Risk Management Specialist:

• leads efforts to ensure continual organizational compliance and ongoing readiness with clinical quality and patient safety standards and regulations required by The Joint Commission, Massachusetts Department of Public Health/Mental Health and Center for Medicare and Medicaid Services. In this role the Manager proactively plans, implements, coordinates and continually improves the Boston Medical Center's (BMC) efforts related to compliance, accreditation, and licensure requirements, and
• participates in the development, implementation, and coordination of a highly visible, proactive institution-wide program to maximize the safety of services delivered to BMC patients. The Specialist responds to patient harm events, learns from individual cases, identifies risk trends, and actively educates leaders, administration, clinicians and staff regarding methods to maximize patient safety and simultaneously reduce professional liability claims.

Position: Accreditation, Regulatory and Risk Management Specialist (Brockton)

Department: Brockton

Schedule: Full Time

ESSENTIAL RESPONSIBILITIES / DUTIES:

Accreditation/ Regulatory Responsibilities

• Serves as the organizational expert for The Joint Commission (TJC), Department of Public Health (DPH), Department of Mental Health (DMH), Centers for Medicare and Medicaid Services (CMS) standards, regulations and conditions of participation.
• Responsible for the interpretation and communication of regulatory and licensing requirements throughout the organization.
• Provides education and consultation to administrative and clinical leadership, staff and faculty throughout BMC regarding the requirements of accreditation and regulatory organizations.
• Provides guidance and assistance to departments, sections, units and programs regarding improvements needed to ensure compliance with requirements of TJC, DPH, DMH and CMS.
• Facilitates development of tools, policies, and procedures, and learning aids to promote compliance with standards.
• Provides timely communication regarding new and revised TJC, CMS, DPH, DMH standards and interpretations to administrative and clinical leadership, staff and faculty.
• Works closely and builds effective working relationships with accreditation and regulatory agencies, i.e., The Joint Commission, DPH, DMH and CMS.
• Responsible for all aspects of the plan to ensure continual readiness with the clinical regulatory and accreditation requirements of the TJC, DPH, DMH and CMS.
• This includes but is not limited to: Development, coordination, and implementation of the continual readiness plan; Ongoing assessment of the continual readiness plan; identification of needed improvements; and preparation and implementation of plans to achieve needed improvements
• Organizational, department, section, unit and program assessments and identification of risk
• Plan and scheduling readiness mock surveys
• All ongoing communication with regulatory agencies regarding survey and readiness activities
• Development of remedial action plans
• Responding to agency requests for revision and corrective action plans
• Responsible for communication of the continuous readiness plan to leadership and key groups throughout BMC. Responsible for ensuring preparation of reports assessing institutional, department, section, program and unit compliance with accreditation and regulatory requirements. Ensure that administrative and clinical leadership are continuously aware of BMC readiness for TJC, DPH, DMH and CMS surveys, including description of specific issues that are in need of improvement. Leads a coordinated response to unannounced external accrediting or regulatory agency visits such as TJC, DPH, DMH or CMS. Serves as a member on committees as deemed appropriate.

Risk Management Responsibilities

• Investigates and analyzes actual and potential patient/visitor safety events (near-misses) for improvement opportunities and for the potential for legal action, with coaching to increasing independence.
• Activities include, but are not limited to chart review, staff/provider interviews, policy review, best practice research and observation activities.
• Utilizes an online incident reporting system for tracking patient safety events.
• Participates in activities to use this database to identify trends and opportunities to improve patient safety.
• Facilitates organization and operationalization of root cause analysis activities on assigned cases.
• Participates in the "on call" system to provide immediate consultation, recommendations and mitigation to hospital staff in responding to adverse events.
• Participates in follow-up action plans required to minimize patient safety risks.
• Prepares reports to external regulatory agencies with increasing independence, as assigned.
• Actively collaborates with Quality and Patient Safety staff to identify and mitigate local and organizational trends that impact patient safety and to support implementation of safer processes and systems of care.
• Actively collaborates with Claims Department to assist BMC efforts to minimize legal/financial liability.
• Actively participates in clinical case review and case learning committees.
• Facilitates committee operations as assigned.
• Help to ensures compliance with various codes, laws, rules and regulations concerning patient care, including those mandated by state, federal agencies and accreditation standards.
• Demonstrates understanding legislative and regulatory activities related to patient safety and health care risk management.
• Assists in the development, maintenance and revision of policies and procedures to improve patient safety and minimize loss exposure.
• Ensures policies and procedures meet regulatory criteria and are communicated to employees.
• Develops and presents educational sessions on patient safety and professional liability risk reduction to physicians and employees.
• Assists clinical chairs and department chiefs to design patient safety and risk management programs specific to their individual areas.
• Periodically reports on risk management matters and prepare reports for various committees and boards.
• Responsible for ensuring that all information necessary to prepare for the defense of claims is collected and properly maintained in a timely manner, including the preparation of reports of investigation.

(The above statements in this job description are intended to depict the general nature and level of work assigned to the employee(s) in this job. The above is not intended to represent an exhaustive list of accountable duties and responsibilities required).

JOB REQUIREMENTS

EDUCATION:

• Bachelor's Degree in nursing required
• Graduate degree (Masters or Doctorate) preferred

CERTIFICATES, LICENSES, REGISTRATIONS REQUIRED:

• Registered Nurse with CPHRM preferred

EXPERIENCE:

• Requires at least 5 years of direct clinical care. Minimum of 1 year in accreditation, regulatory and risk management.

KNOWLEDGE AND SKILLS:

• Must have interpersonal skills necessary to deal effectively with a administrative and clinical leadership, staff, Clinical Chairpersons, and other healthcare professionals
• Ability to effectively interview individuals and groups from diverse professional backgrounds
• Maintain strictness confidentiality of information
• Ability to collect event information and organize into a coherent narrative
• Highly self-motivated. Ability to manage multiple projects simultaneously and adhere to work deadlines.
• Ability to inspire trust and be seen as someone who provides support and assistance
• Excellent verbal and written communication skills.
• Excellent presentation skill including ability to speak before large audiences and prepare and provide Power Point presentations.
• Excellent computer skills including Microsoft Office; ability to learn new computer applications such as adverse event reporting software.
• Ability to develop effective relationships with a broad array of people from diverse backgrounds.
• Strong interpersonal skills; ability to establish supportive, collegial relationships.
• Superior organizational skills to manage a large volume of incoming data, information, reports, etc. in paper and electronic formats.
• Ability to create and deliver appealing and compelling presentations to a variety of audiences including clinicians, staff, faculty, administration and governance groups.
• Excellent written and verbal communication skills.
• Demonstrated skill in change management and quality improvement.
• Knowledge of clinical terminology.
• Strong computer skills including Microsoft Office platform-Word, Access, Excel, E-mail. Web/Internet.
• Ability to learn and effectively use computer software, such as electronic health records and data entry.
• Excellent English communication skills (oral and written).

Equal Opportunity Employer/Disabled/Veterans