Job Description

Culture of Excellence Responsibilities;

* See everyone as worthy of respect and attention

* Design care and services for and with each patient

* Recognize that patients see quality service as quality care

* Make it a priority to assist patients, visitors and colleagues

* Take advantage of learning and growth opportunities

* Understand organizational goals and priorities

Job Specific Responsibilities;

* Completes compliance activities at NWH, ensuring adherence to MGB standardized processes around tracer activity, site level preparedness activities, and measuring/monitoring compliance

* Supports the Quality and Clinical Compliance team in completing compliance activities to ensure regulatory standards are met

* Responsible for submitting required documentation and reports to relevant accrediting and regulatory bodies (DPH, CMS, TJC, BORIM)

* Executes quality performance improvement plans, and partners with local teams and department or floor-based teams to implement improvements as needed

* Executes and tracks performance of process changes or performance improvement activities

* Prepares reports and presentations as needed

* Supports local training and educational programs as needed

* Understands data provided by the system team and uses knowledge of local practices and culture to identify areas of opportunity for improvement as well as communicates to the system areas which are at risk

* Provides strong bi-directional communication between the system and the site

* Meet annual competency and retraining requirements

* Maintains established hospital and departmental policies and procedures, objectives, confidentiality, patient satisfaction, employee satisfaction, quality improvement program, safety, compliance, and environmental standards

* Maintains professional growth and development through attendance at seminars, workshops, conferences, or in-services to stay abreast of current trends

* Attends meetings as required

* Coordination and scheduling of multi-department/stakeholder meetings under direction the Sr. Manager

* Provide scribe activity for Joint Commission readiness efforts and surveys

* Ensures meeting participants have accurate meeting logistics (location, directions, etc.)

* Meeting preparation and minutes for multiple departments

* Other ad hoc administrative duties and projects as assigned

* Undergraduate degree required. Commensurate years of experience in the field of quality and compliance will be considered.

Experience

* Minimum of 2 years of experience in quality and clinical compliance within a hospital-based quality department strongly preferred.

* Knowledge of principles of quality measurement, governmental and regulatory quality requirements, process improvement required.

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