Job Summary: Responsible for assisting the director to ensuring the facility is in compliance with Joint Commission, state and federal standards; participation in all regulatory body surveys, i.e., Joint Commission, State Licensing Review, CMS Validation surveys. This includes staying current with all applicable standards, educating facility staff about Joint Commission and CMS standards, preparing the facility for accreditation surveys.
Responsible for planning and organizing the performance improvement program to meet the needs of the hospital. Provides education to medical staff, hospital staff and Governing Body as requested. Facilitates performance improvement activities throughout the hospital. Maintains oversight responsibility for all performance improvement activities conducted throughout the institution.
Assists the Director to perform clinical risk management functions. Assists to coordinate risk programs with all hospital departments, and administration. Prepares reports of real and potential risk situations for the Governing Body, medical staff, administration, hospital departments and committees, as appropriate. Responsible for monitoring methods to avoid, eliminate and/or reduce risk situations associated with the provision of patient care and services.
· Current Registered Nurse Licensure to practice in the state of Kentucky,
· Bachelor of Science Degree in Nursing, health care management or similar appropriate field preferred
· Five years experience in a hospital setting;
· 1 or more years of previous experience in risk management, legal or insurance related field; or
· Previous experience in performance improvement activities preferred.
· Able to effectively communicate in English, both verbally and in writing.
· For physical demands of position, including vision, hearing, repetitive motion and environment, see following description.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the position without compromising client care.|