Overview

In 2020 united in a fierce commitment to deliver the highest quality care and exceptional patient experience Virginia Mason and CHI Franciscan Health came together as natural partners to build a new health system centered around the patient: Virginia Mason Franciscan Health. Our combined system builds upon the scale and expertise of our nearly 300 sites of care including 11 hospitals and nearly 5000 physicians and providers. Together we are empowered to make an even greater impact on the health and well-being of our communities.

Responsibilities

This job is responsible for providing operational support and overall coordination for the strategic implementation of licensing and accreditation programs consistent with state and federal rules and regulatory requirements. An incumbent assures all facets of licensing and accreditation are identified and coordinated into a comprehensive plan for Virginia Mason Franciscan Health (VMFH) and that assigned hospitals and clinics are aligned with The Joint Commission (TJC) and standards established through state and federal regulations.

An incumbent facilitates on-going regulatory readiness and compliance activities through extensive rounding on VMFH clinical and non-clinical departments. Work also includes: 1) policy and procedure implementation; 2) survey preparation; survey management and follow-up; 3) assessment of compliance with VMFH standards and reporting of vulnerabilities to key stakeholders; 4) delivering, in response to identified/potential deficiencies, training to management, educators and staff; and 5) providing guidance and coaching to management aimed at achieving a state of continuous readiness surrounding licensure, accreditation and certification programs.

Incumbent is accountable for keeping knowledge and skills current in assigned subject area through self-education, community networking and professional organization offerings.

Responsibilities include:

• Plans and leads accreditation and licensing program activities for full compliance of The Joint Commission (TJC) accreditation, Washington State Department of Health (DOH), Conditions of Participation (CoPs) and other state and federal standards, rules and regulations in assigned hospitals.
• Identifies regulatory compliance gaps and mentors leadership in developing appropriate plans to address and close the gaps to achieve outcomes, promote safe practices and achieve sustainable compliance with regulatory standards; works collaboratively on VMFH annual intra-cycle monitoring of compliance with TJC standards, including with identified opportunities for improvement and corrective action plans.
• Serves as a coach, facilitator, and resource for patient safety initiatives and regulatory program activities.
• Provides consultative services, coaches and facilitates key stakeholders and staff to help mitigate/resolve potential safety, health and environmental issues/deficiencies/violations (within defined scope of responsibility) in accordance with established requirements and hospital policy.
• Works Collaboratively with key stakeholders in Patient Safety, Risk management, Quality, Infection Prevention, Informatics, organized Medical Staff and Education Services to ensure communication and implementation of system quality improvement goals and initiatives.

Qualifications

• Bachelor’s degree in a healthcare related field, graduation from an accredited school of nursing, and four years of progressively responsible experience in a clinical or acute care setting that demonstrates the attainment of the requisite job knowledge, skills and abilities.
• Or, any equivalent combination of education and experience which meets licensure requirements and provides the required knowledge, skills and abilities to perform the essential functions of the position.
• Knowledge of, and experience in performance improvement methodologies; quality measurement; and data analysis using statistical principles.
• Knowledge of the content, intent and application of federal and state standards and regulatory requirements pertaining to matters within designated scope of responsibility.
• Knowledge of professional clinical principles, standards and practices sufficient to identify compliance deficiencies and/or issues.
• Knowledge of safety/risk management and regulatory accreditation/survey processes relating to health care organizations.

Licensure/Certification:Current RN licensure by the Washington State Nursing Commission.