Description SHIFT: Days (rotating weekends) SCHEDULE: Full-time St. David's South Austin Medical Center is part of St. David's HealthCare , one of the largest health systems in Texas, which was recognized with a Malcolm Baldrige National Quality Award in 2014. St. David's South Austin Medical Center is an acute care facility with 316 beds, offering a range of complex specialties and sub-specialties, including a nationally accredited oncology program with the area's only adult bone marrow transplant program; a trauma program that includes all of the capabilities and programmatic elements of a Level II trauma center to treat the most severely injured and critical patients; a comprehensive cardiac program; full-service maternity and newborn care with Level I and II nurseries; and two full-service emergency centers in the communities of Bee Cave and Bastrop. POSITION SUMMARY The position is designed to provide an organized approach to the development and revision of policies, procedures, forms, orders, and survey readiness. The position requires familiarity with regulatory and compliance standards, acute care hospital policy and procedures. The individual in this position must be self-directed with positive interpersonal skills and be able to effectively interface with staff, management, and medical staff members. PRINCIPAL RESPONSIBILITIES Monitors accreditation, regulatory standards, and related laws and communicates changes to the organization (i.e., HCA, TJC, CMS, TDH, etc.). Develops timelines and action plans to assure readiness and a system of checks and balances to assess compliance for any survey (accreditation or regulatory). Coordinates the efforts of the organization to ensure compliance with standards and regulations. Develops and facilitates \"mock\" survey processes to assist with education of staff, medical staff, and leadership assessing and facilitating survey readiness. Participates in hospital surveys (scheduled and unannounced), oversights development of correction actions, measures of success, and monitors completion and compliance to plans of action. Develops communication methodology to provide a regular updates, feedback, and reporting to Senior Management, Medical Staff , Leadership in collaboration with the Director. Develops networking with other facilities for collaborative market approaches to standards, policy, procedure, forms, and orders as appropriate. Works directly with Director of Risk Management and department leadership facilitating investigations, focus analysis, and/or root cause analyses through the direction of the Director of Quality Outcomes Management. Oversights the development, review, and revision of policies and procedures, forms, and orders to help ensure accuracy, consistency, clarity, and compliance. Researches sources cited in policies and procedures. Ensures policies and procedures are evidence-based. Assists department personnel in identifying conflicting policies and procedures to resolve conflicts and revise manuals accordingly. Manages publication of policies and procedures. Assist with the tracking of forms and orders in collaboration with the HIM Director in eDemand. Oversight includes ensuring timely development, editing, and updating. Assists in the communication of new and/or revised / reviewed policy, procedure, forms, and orders so all departments are aware of changes. Works in collaboration with Clinical Education to develop and present education on new, revised policies, procedures, forms, and orders. Acts as a resource and liaison to departments, senior leadership, and the medical staff of the facility for education, interpretation and suggestions for evidence of compliance related to any accreditation or regulatory standards, and policy and procedures. Qualifications EDUCATION REQUIRED Graduate from an accredited school of Professional Nursing (BSN preferred) LICENSED/CERTIFICATION REQUIRED Registered Nurse licensed by the Texas Board of Nurse Examiners. EXPERIENCE REQUIRED Minimum two years' experience as a Registered Nurse in an acute care setting. Prefer recent work history in a regulatory or quality management aspect of acute care. Working knowledge of regulatory standards related to healthcare, i.e., JCAHO, professional licensure laws, TDH, CMS, etc. QUALIFICATIONS Ability to communicate effectively, comprehends complex clinical and financial data; organize, prioritize and manage time efficiently. Must be able to communicate effectively with a wide range of hospital personnel, physicians, patients/family members and representatives of outside agencies. Ability to utilize Microsoft Office products.
Associated topics: care, care unit, ccu, intensive, intensive care, intensive care unit, maternal, nurse clinical, recovery, transitional