Category: Management/ Professional Schedule: Full-time
Facility: Norwood Hospital Shift: Day shift
Department: NWH Quality & Safety Hours: 8:00am-4:30pm
Req Number: 43736 Union: No
Job Details:

This position is a dual role encompassing Quality, Patient Safety and Accreditation/ Regulatory Compliance Coordination. Requires a highly trained professional, with demonstrated passion for Quality, patient safety and regulatory readiness who will work in collaboration with the Risk Manager and Regional Director of Quality and Safety to implement the activities identified in the System-wide Quality and Safety Plan consistent with board approved plans and regulatory and standard setting agencies
The DQARRPS will be expected to collaborate and provide leadership to hospital staff daily to identify and remove barriers to ensure an error-free clinical and non-clinical setting consistent with defined regulating and accreditation standards (Joint commission, Medicare Conditions of Participation, Departments of Public Health, Mental Health, etc). The primary role of the DQARRPS is to ensure a continuous state of readiness and meeting all Joint Commission, CMS and DPH standards by standardizing processes for evaluation of compliance of standards, identifying opportunities for improvement, implementing changes to hospital operations to meet expected regulatory readiness, measuring effectiveness of interventions with standardized tracer and audit activities. The In doing so, the DQAARPS will foster a culture of continuous improvement and coordinate the systematic implementation of effective practices designed to reduce error and improve patient outcome.


• Coordinate the quality and regulatory compliance program to meet the standards identified by the JCAHO, DPH and CMS. Support project structure to insure all staff is involved in regulatory readiness on a daily basis. Works with administrative and clinical leadership to insure they recognize their role in preparation for regulatory readiness. Is supported by the hospital leadership in assuring this process is hospital wide.
• Is knowledgeable of all standards specific to the Joint commission, CMS, DPH, DMH, OSHA, FDA, etc.
• Is knowledgeable and versed in the completion of the annual Periodic Performance Review including identification of hospital vulnerabilities that require changes to ensure ongoing survey readiness
• Collects and administers necessary tools and reports to monitor organization's activities specific to regulatory readiness (tracer rounds, chart audit, etc).
• Develops a team approach (chapter leaders) to ensure sharing of information and understanding of standards across the organization
• Identifies and implements educational materials and agendas for all organization stakeholders to ensure continuous regulatory readiness.
• Develops action plans for all noncompliant standards with measurement of effectiveness.
• Develops and implements a plan for responding to the arrival of unannounced and announced survey team(s).
• In coordination with the Regional Director of Quality and Safety and the Risk Manager, manages all survey activities from arrival, coordination of survey activities to exit exercises inclusive of successful completion of any action plan associated with the survey process to ensure ongoing accreditation.
• Ensures the organization is always appraised of all standard changes/updates and implements plans to ensure compliance with changes in a timely manner.
• As it relates to standards specific to patient safety, provides over-site in the implementation of improved systems for tracking, evaluating, and communicating patterns in patient safety for the hospital.
• Provide support and guidance to the clinical leadership in meeting the goals within the accreditation and patient safety agenda at the local hospital. Works closely with the system's clinical leadership, to implement pilot programs designed to eliminate the following:  preventable mortality, adverse drug events, falls, pressure ulcers, surgical complications, nosocomial infections, and other patient safety goals as defined by the Joint Commission.
• Supports the collection of regulatory driven patient safety data for trends and recommend changes, as appropriate, thereby improving the safety of care at the hospital.
• Fosters and maintains collaborative relationships with external agencies. Reviews and evaluates services to ensure that safety and regulatory recommendations are implemented and desired results are obtained.


• BS or MS in health care field preferred.  2-5 years experience in the role of regulatory coordination/readiness in hospital setting.
• Highly motivational communication skills accompanied by the ability to analyze and present data to influence behavior, stimulate innovation, promote best practices, and drive organizational change.
• Excellent presentation style, including the ability to present data to clinicians and staff at all levels of the organization.
• A highly skilled change agent with demonstrable sensitivity to the interpersonal, group dynamic, organizational, political, and perceptual issues associated with change.
• Results orientation accompanied by the skill set required to conceptualize, implement, and operationalize a user-friendly clinical excellence and patient safety program.
• Demonstrated ability to create and sustain momentum through relationship building, and collaborative management.



back to top