JOB SUMMARY: Participates in WFBMC system-wide activities that support the achievement and maintenance of an effective clinical compliance program related to State and Federal regulations and Joint Commission standards. Demonstrates initiative and creativity in addressing compliance and patient safety issues and utilizes effective communication skills. Establishes and maintains collaborative relationships throughout the health system to facilitate resolution of compliance and patient safety issues.
REPORTS TO: Director, Clinical Compliance & Regulatory Services with matrix reporting to the President of Lexington Medical Center.
EDUCATION/EXPERIENCE: Graduate from an accredited school of nursing, Bachelor's degree in Nursing with five years' experience in a hospital/healthcare system required. Master's degree in nursing or a related field preferred. Supervisory, teaching or leadership role experience preferred. Previous experience as a regulatory agency surveyor preferred.
LICENSURE, CERTIFICATION, and/or REGISTRATION: Current RN licensure in good standing in the State of North Carolina. Relevant certification required within one year of hire.
1. Maintains knowledge of new regulations and standards. Facilitates the incorporation of regulations and standards into policies, practices, and processes. Through assessments and utilization of the tracer methodology, prepares the WFBMC system for Joint Commission accreditation and disease-specific certifications, CMS validation and program specific certifications, service line designations of excellence and other program specific certifications or accreditations.
2. Facilitates activities during on-site survey activities through active participation in survey and reporting of findings. Participates in the development, implementation, and submission of corrective action plans related to areas of clinical non-compliance.
3. Promotes an environment conducive to patient safety by identifying, investigating, and reporting potential areas of compliance vulnerability and risk. Collaborates with others throughout the medical center to resolve patient safety issues. For policies affecting patient care practices, facilitates the development, review and revision of policies, including the coordination of the approval process.
4. Participates in the review and investigation of allegations and other incidences requiring possible report and prepares report for submission to outside agencies as needed.
5. Collaborates with WFBMC Leadership to implement actions in order to improve patient care and support a system of continuous quality improvement and patient safety.
6. Participates in the monitoring of Joint Commission standards and National Patient Safety Goals, Federal and State regulations compliance and plans of corrective action. Prepares reports as requested for submission through the appropriate Quality Assurance and Performance Improvement (QAPI) structure.
7. Ensures quality and compliance improvement information is reported timely to Leadership for action planning. Recommends changes in nursing practice based upon identified opportunities from quality and compliance monitors, best practices, and current literature to improve patient care.
8. Assumes responsibility for self-directed professional growth. Attends in-services, workshops, seminars, and professional meetings to keep abreast of current nursing practice and quality improvement trends. Participates in planning and presenting educational offerings. Participates in professional organizations and activities.
9. Maintains expertise through continuing education programs and through formal and informal practice. Shares information with colleagues utilizing his/her knowledge as a teacher and consultant.
Organization, planning, and delegation skills
Sound and timely decision-making skills
Highly motivated and results-oriented
Fairness and consideration for all employees regardless of race, religion, sex, or other protected class
Ability to work independently
Effective leadership, teaching, coaching, and interpersonal communication skills including verbal, nonverbal, and active listening skills
Experience with microcomputer systems, spreadsheet and database program applications preferred
Clean, well lit, and comfortable climate
Potential exposure to contamination with blood or bodily fluids, requiring protective equipment
Subject to highly stressful, dynamic conditions
Internal Number: 36753
About Wake Forest Baptist Health
Wake Forest Baptist Medical Center is a nationally prominent academic medical center in Winston-Salem, with an integrated health care network that incorporates hospitals, clinics, physician practices, diagnostic centers and other primary and specialty care facilities serving the residents of 24 counties in northwest North Carolina and southwest Virginia.