Job ID 20000GSD
Available Openings 1
Position Specific Information This is a remote role
PURPOSE AND SCOPE:
Responsible for coordination and management of regulatory and clinical compliance and quality audits/surveys for the assigned locations. Manages the local execution and implementation of company, divisional and departmental strategies and initiatives pertaining to clinical quality within the assigned facilities/locations. Works closely with the Operations management and clinical staff to promote utilization of continuous quality improvement principles, procedures and methods to ensure superior patient outcomes within the assigned facilities/centers. Responds to, investigates and ensures appropriate resolution regarding regulatory and quality compliance questions, issues and concerns for the assigned locations.
PRINCIPAL DUTIES AND RESPONSIBILITIES:
- Provides guidance, support and expertise to the assigned Vascular Care Access Centers with respect to actions and activities related to due diligence, clinical orientation and clinical training for new and existing staff and for implementation of company and divisional quality programs and initiatives.
- Works with the Director of Clinical Resources to ensure consistent, effective and efficient application of clinical policies, processes, and procedures including coordinating with the appropriate personnel to provide education and training to ensure compliance with all regulatory requirements.
- Ensures assigned centers' compliance with Joint Commission accreditation standards by conducting annual Joint Commission mock surveys for each center.
- May perform specific elements of TJC mock survey as needed to address specific Access Center needs.
- Identifies deficiencies and collaborates with Operations management and clinical staff to implement TJC Mock Survey Plan of Action Items to address the identified issues.
- Acts as a Joint Commission Standard chapter leader and liaison for the assigned region and locations.
- Provides input into revising the TJC Standards and Mock Survey and manages the implementation of the new updated Mock Survey.
- Coordinates and manages other surveys to ensure compliance with company and divisional policies and procedures and other regulatory requirements. Surveys include the annual Medication Management Survey, the annual Environmental survey.
- Conducts regular focused safety audits per OSHA and TJC standards and requirements. Identifies and works with the appropriate operations staff and the Center Medical Director to address variances and anomalies escalating as needed to the FVC Director Quality Initiatives.
- Tracks, trends, and analyzes Adverse Events following up on Adverse Event reports, notifying the Center Medical Director and updating the FVC Director Quality Initiatives and RVP as needed.
- Utilizes knowledge of the TJC Standards as set forth in the Infection Prevention protocols to ensure Access Center compliance providing guidance and expertise as needed to clinical staff regarding identified issues and ensuring the appropriate corrective actions are taken.
- Supports improved patient outcomes by collaborating with regional operations management and facility/center staff, Director and Manager Quality Improvement regarding establishing quality goals, identifying risk areas, and opportunities for improvement assisting with root cause analyses as appropriate. Makes recommendations for process changes to address the issues.
- Conducts local monitoring and trending analyses utilizing standard templates developed by Director QI to ensure consistent reporting and data for comparative analyses.
- Ensures Clinical Staff receive annual in-services and works answers any follow-up questions pertaining to quality issues and protocols.
- Ensures Vascular Center compliance with TJC Quality Metrics and FVC Quality Outcomes, and provides guidance if needed
- Assists CM with organizing and conducting QA/Patient Safety Meetings, Staff Meetings, Code Blue Drills, Fire Drills, and Emergency Drills.
- Conducts monthly Quality Assurance Improvement meetings with Operations management and clinical staff to evaluate effectiveness of Quality Initiatives to ensure compliance and to identify areas of concern.
- Maintains current knowledge of revised/upcoming revisions to Local, State, Federal, Accrediting Body, Professional Organization regulations/standards/recommended practices and ensures we are in compliance with the state regulations for professional licensure in the states we operate. Communicates these requirements to Operations, Quality and HR representatives.
- Attends FVC Clinical Services Team monthly meeting to provide updates regarding the clinical quality status of the assigned region.
- Provides regular updates as to the RVP regarding Quality related issues, initiatives status etc.
- Other duties as assigned.
Additional responsibilities may include focus on one or more departments or locations. See applicable addendum for department or location specific functions.
PHYSICAL DEMANDS AND WORKING CONDITIONS:
- The physical demands and work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- Day to day work includes desk and personal computer work and interaction with patients, facility staff and physicians.
- The work environment is characteristic of a health care facility with air temperature control and moderate noise levels. May be exposed to infectious and contagious diseases/materials.
- The position requires travel between assigned facilities and various locations within the community. Travel to regional, Business Unit and Corporate meetings may be required.
- RN Degree required; Bachelor's Degree desirable
- Current RN License
EXPERIENCE AND REQUIRED SKILLS:
- At least 3 years center or clinical management experience and at least 2 years as a nurse in the vascular access center.
- Must be knowledgeable with all Local, State, and Federal Regulations affecting Access Centers and Clinical Staff
- Must have a good understanding of the relationship between providers of healthcare services and regulatory agencies.
- Must be able to analyze and propose alternative solutions to assist in resolving sensitive to complex issues.
- Experience in quality, risk management, case management, infection control.
- Must have good verbal and written communication skills.
EO/AA Employer: Minorities/Females/Veterans/Disability/Sexual Orientation/Gender Identity
Fresenius Medical Care North America maintains a drug-free workplace in accordance with applicable federal and state laws.
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