Responsible for the coordination of a broad range of activities that sustain ongoing awareness of and compliance with organization-wide regulatory compliance requirements, including Joint Commission and Department of Health (DOH) standards, including all associated follow up reporting.
Essential Job Functions:
1. We are the stewards of our culture. How we embrace and live our values and these principles cultivates our culture. We are accountable for exceptional outcomes and for constant improvement. 2. We are committed to continuous, incremental improvement to eliminate waste, inefficiency, ineffective communication, and variations in our processes. 3. We are “teachers and coaches” supporting the professional growth of our staff, to help our teams achieve their highest potential. We are committed to learning and growing as leaders in the application of these principles. 4. We are consistently responsive to those we serve. We listen and communicate effectively, always seeking first to understand and then to be understood. We are inclusive and transparent in our decision making and communications. 5. We role model healthy and rewarding personal lives that are balanced with the demands or our work. We find opportunities every day to genuinely recognize and celebrate the excellent work of our staff, physicians and volunteers 6. Works collaboratively with all levels of staff within the organization, including senior leadership, medical staff leadership, nursing and support staff to build a strong knowledge of and compliance with regulatory standards/requirements across the organization. 7. Leads and coordinates preparation for Joint Commission and other accreditation, certification and regulatory reviews; manages the survey processes including survey schedule, surveyor support and required follow up. 8. Provides the organization wide coordination of regulatory compliance and survey readiness for all services within Evergreen including EMG, Home Care, Hospice and specialty clinics. 9. Responsible for investigating, follow up and appropriate notification of significant adverse/reportable events.
REQUIRED for the position: • Bachelor’s degree in Nursing or a related field • 5 years of related clinical experience • Knowledge of Joint Commission Standards, Survey process or related requirements. • Knowledge of methods of data collection, manipulation, interpretation, and presentation of information. • Demonstrated ability to lead multidisciplinary organization-wide teams. • Knowledge of health care trends, care processes, and best practices that support regulatory requirements. • Experience with the Tracer Methodology. • Demonstrated ability to establish cooperative working relationships with diverse groups and individuals, medical staff, and other health care disciplines. • Knowledge of and demonstrated experience with improvement techniques (methods), including root cause analysis, cause and effect analysis, and failure mode and effects analysis as applied to the health care setting. • Skills with information management systems to support regulatory compliance, including database management, database analysis and reporting, and flowchart software. • Requires skill to plan, organize, and direct teams and to negotiate effectively with management to accept and implement recommendations, where proposals involve substantial organizational resources, require extensive changes in established procedures, or may be in conflict with the proposed requirements. • Knowledge in and the ability to apply the principles of project management and change management. • Demonstrated organization, facilitation, communication, and presentation skills. • Computer skills including the use of Microsoft products in a Windows? environment, as well as spreadsheet and QI data display software. • Familiarity with clinical documentation; i.e. patient chart. • Previous leadership responsibility in healthcare setting.
DESIRED for the position: • Master’s degree
Internal Number: req# 32111
EvergreenHealth is an integrated two-hospital healthcare system offering a breadth of services and programs that is among the most comprehensive in the region. Formed in 1972 as a public hospital district, we now serve nearly 850,000 residents of our service area in north King and south Snohomish counties, with medical facilities located throughout the area for easy access.
Our goal is to improve the health of every life we touch by delivering the highest quality care and absolute patient safety, and we’re honored to be recognized as by Healthgrades as one of America's 100 Best Hospitals (2018). We take great pride in offering the latest medical technology, but our care is set apart by the personal touch provided by our staff of nearly 3,000, our 950 physician partners and our 1,100 volunteers.
Our main campus is located in Kirkland, and includes a 318-bed medical center and four medical specialty buildings. In 2015, we expanded to include EvergreenHealth Monroe, an accredited, full-service public hospital district located in Monroe, WA.
Our EvergreenHealth Medical Group, a nearly 300 member physician multispecialty group, provides 12 primary care centers, five urgent care...s and over two dozen specialty care practices located throughout our service area.
All told, we offer care in 70 clinical specialties, from primary care to specialty care, from the family maternity center to senior care and hospice care. To further bolster our capabilities and extend access to services, EvergreenHealth has partnered with two other regional healthcare leaders, Overlake Medical Center and Seattle Cancer Care Alliance, and with the Eastside Health Alliance. We also serve the community with our 24/7 Nurse Navigator and Healthline and hundreds of community health education classes and presentations each year.