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General Summary

Under limited supervision, ensures organizational compliance with quality measures and other

performance indicators required by regulatory and accrediting entities. Provides input into

establishing goals, objectives and performance standards. Ensures compliance with policies, quality

standards, Joint Commission, CMS and DHMH regulations and codes.

Is responsible for the coordination of patient safety activities, and regulatory compliance activities

The position encompasses various roles (e.g., coordinator, educator) and requires effective

interpersonal and management skills to motivate staff. . In addition, the individual will assist with the

management of the UMMC Event Reporting System, and will provide support to the Hospital's

Performance Improvement Program. Duties include working with UMSJMC departments on risk

reduction strategies to enhance patient safety and meet regulatory compliance.

Provides the tools, techniques and skills necessary for patient safety, outcomes measurement, process

improvement as well as thorough and credible root cause analysis processes. Works with leadership,

staff and physicians to provide a planned, systematic, organization-wide approach to identify,

measure, monitor, and evaluate patient safety and improvement activities. Helps develop and revise

policies and procedures; interprets and ensures compliance with UMSJMC policies, quality standards,

regulations and codes. Develops and maintains interactive and collaborative relationships with key

medical staff.

2. Principal Responsibilities and Tasks

The following statements are intended to describe the general nature and level of work being

performed by people assigned to this classification. They are not to be construed as an exhaustive list

of all job duties performed by personnel so classified.

The following statements are intended to describe the general nature and level of work being

performed by people assigned to this classification. They are not to be construed as an exhaustive list

of all job duties performed by personnel so classified.

MC Patient Safety and Regulatory Compliance Coordinator

A. Provides leadership and/or assistance with hospital-wide activities to evaluate and improve

adherence to the Joint Commission accreditation standards, CMS Conditions of Participation, and

MD State regulations in preparation for all surveys.

1. Assists with preparation and participates in organizational visits from accrediting agencies.

2. Participates in survey command center activities which may include but is not limited to:

keeping track of and fulfilling surveyor requests for environmental logs, policies and

procedures, employee files, contracts, etc., responding to emails and phone calls.

3. Assists and participates in organization-wide Joint Commission readiness activities including

tracers; monitoring and educating staff in regulatory compliance and hospital policy

requirements.

4. Enters tracer data into accreditation tracking tool; reports from these data are provided to staff

to use in staff education and improving compliance with Joint Commission standards and

CMS Conditions of Participation (COPs).

5. Assists with internal regulatory assessments to evaluate and validate compliance with current

standards set forth by various external regulatory agencies.

6. Abstracts data to evaluate medical center's compliance with Joint Commission standards and

CMS Conditions of Participation (COPs).

7. Monitors action plan progress in response to external audits and surveys through concurrent

and retrospective chart review.

8. Works with providers to monitor and promote quality improvement activities related to

regulatory requirements and clinical documentation in the medical record.

9. Participates in Epic UDCs to assure documentation elements are properly embedded in the

EHR to meet regulatory standards and conditions of participation.

10. May assist in State and Federal Quality projects to obtain comparative data on quality and

regulatory indicators.

11. Attends hospital based committee meetings as assigned.

B. Plans, organizes, and directs activities centered on hospital compliance with the Joint

Commission, CMS and other external reporting entities.

1. Ensures compliance with established quality measures.

2. Assures data quality, reliability and validity; compiles and enters data into designated data

base.

3. May serve as steward for the System to validate data submissions to the Joint Commission

and CMS.

4. Abstracts data from EHR to evaluate medical center's compliance with the Joint Commission

and CMS guidelines.

5. Analyzes data to identify opportunities for improving organization's performance.

6. Keeps staff up-to-date with on-going changes in documentation requirements..

7. Provides regular feedback to staff and provides support as requested in quality & safety

activities.

8. May facilitate development of department level quality initiatives.

MC Patient Safety and Regulatory Compliance Coordinator

33. O. Assists the UMSJMC Patient Safety Officer with reporting to the State and The Joint

Commission.

A. P. Ensures compliance with Regulatory Requirements . Ensures compliance with

external regulators and accrediting agencies (e.g., The Joint Commission, CMS,

Maryland State Department of Health Office of Healthcare Quality (OHCQ).

Ensures that Medical Center and department policies, procedures and standards

meet requirements and regulations of regulatory and accrediting agencies related

to patient safety.

Other Tasks:

1. Travel to all University of Maryland Medical Center locations may be needed

2. Knowledge, Skills and Abilities

A. Demonstrate expertise in the use of data, data validation and production of reports.

B. Demonstrate the ability to effectively navigate computer applications for use in abstracting

needed data.

C. Demonstrates the ability to effectively navigate external databases which publicly report quality

data and to retrieve and/or input data.

D. Current and comprehensive knowledge of the methodology and definitions utilized for data

abstraction for core measures is preferred.

E. Highly effective oral and written communication skills are required to work with all levels of

hospital personnel, administrators and clinical staff as well as outside agencies.

F. Ability to work with limited supervision in the management of projects and programs is required.

Initiative and problem-solving skills are needed.

G. Ability to develop collaborative programs and projects with other disciplines is required. Must be

able to contribute to team effectiveness, build relationships and facilitate improvements

H. Self-motivated, independent thinker.

I. Working knowledge of Microsoft word, excel and, power point