Has a working knowledge of current local, state and federal regulation and regulatory agency standards, including JCAHO, BQA (Bureau of Quality Assurance) and Centers for Medicare and Medicaid Conditions of Participation. Has working knowledge of Medical Staff Bylaws and Rules & Regulations. Identified trends for enhancements or changes in services.
Established appropriate work groups to facilitate accomplishments of service area goals and activities, and changes that arise from regulatory agencies.
Conducted and documented regular departmental and specialty staff meetings to maintain open communication with employees. Maintained open communication with multiple external contacts; hospital attorneys, liability insurance representatives, other health care disciplines and peers from other facilities.
Prepared and reports quality and risk issues to Leadership Team, Administrative Team and the Governing Board.
Coordinated complaint process and reports data on a biannual basis.