Director Regulatory:Assistwiththedevelopmentofhospital-wideapproachtoidentifyprocess,defects, trends and/or practice pattern variation through objective review of cases identified with regard to appropriateness based on evidence-based guidelines and outcomes.

The Core Measure Coordinator is responsible for identifying inpatient assigned core measure patients, ensuring compliance of the care team with evidenced-based medical therapies, data abstraction of core measures, and conducting patient education. This position will also coordinate organizational core measure initiatives and performanceimprovementprocessesforassignedareas,identifycasestudiesforreviewandappropriatefollowup. Data abstraction requirements include but are not limited to CMS/TJC Core Measures. Completes IRR validation processforcoremeasures. Participatesinthedatacollection, trendinganddataanalysisofperformanceindicators for Medical Staff monitoring and evaluation of quality, appropriateness and timeliness of care and customer satisfaction.

PreparesOPPElettersforDepartmentChairtoreviewanddetermineactionplan. Screens 100% mortalities monthly for peer review referrals.

Providesexpertiseregardingaccreditationstandards,identify,planfor,communicate,monitorandevaluateactions to comply with existing and new regulations, standards and accreditation requirements throughout the Hospital and Clinic.

ProvidesconsultationtoalldepartmentsontheinterpretationandapplicationofTheJointCommissionaccreditation standards to maintain ongoing readiness:

-PerformingDepartmentValidationTracersusingtheEnvironmentalandChartReviewtools

-Developingandensuringsustainedcompliancewithcorrectiveactionplans

-Servingasamemberofassignedcommittees/teamsandreportsregulatorycompliance

Identifyareasofvulnerabilityandassistdepartmentleadersindevelopingcorrectiveactionplans

InvestigationsHospital-AcquiredConditionsusingevidencebasedcriteriatodetermineifpresentonadmission. Communicates Hospital-Acquired Condition findings to the providers for appropriate follow up

PerformseducationtonursesandmedicalstaffonHospital-AcquiredConditionsandappropriatedocumentation requirements.

Infection Control Preventionist:

Oversees all infection control activities. Have understanding of TJC Infection Control standards. Plans, implements, evaluatesandreportsoninfectioncontrolfunctionsthroughouttheorganization.Participatesinhospitalandmedical staff committees as required. Educates staff on infection control principals. Establishes and implements infection control policies and procedures.

ESSENTIALFUNCTIONS

Coordinatesthedevelopmentandevaluationoftheorganization'sinfectionpreventionandcontrolstrategies, policies, and planning.

Collectsandperformsstatisticalanalysis,interpretationanddisseminationofhealthcareacquiredinfectiondata, including risk assessment, surveillance priorities, and outcomes analysis.

Monitorslocal,stateandfederalregulationsandensurescompliancewithaccreditingandregulatoryagencies' standards and requirements.

Assistswiththedevelopmentofeducationalresourcesandinitiatives.

Monitorsresearchanddevelopmentsinthefieldofinfectionpreventionandcontroltoidentifybestpractices.

Reportsto:DirectorofQuality&Risk

Minimumeducation

Associate’sdegree in nursing- Required

RequiredSkills

Requirescriticalthinkingskills,decisivejudgmentandtheabilitytoworkwithminimalsupervision.Mustbeableto work in a stressful environment and take appropriate action.

Licenses:CurrentRegisteredNurse(RN)licensetopracticeinthestateofAlabama.