Director Regulatory: Assist with the development of hospital-wide approach to identify process, 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 performance improvement processes for assigned areas, identify case studies for review and appropriate follow up. Data abstraction requirements include but are not limited to CMS/TJC Core Measures. Completes IRR validation process for core measures. Participates in the data collection, trending and data analysis of performance indicators for Medical Staff monitoring and evaluation of quality, appropriateness and timeliness of care and customer satisfaction.

Prepares OPPE letters for Department Chair to review and determine action plan. Screens 100% mortalities monthly for peer review referrals.

Provides expertise regarding accreditation standards, identify, plan for , communicate, monitor and evaluate actions to comply with existing and new regulations, standards and accreditation requirements throughout the Hospital and Clinic.

Provides consultation to all departments on the interpretation and application of The Joint Commission accreditation standards to maintain ongoing readiness:

-Performing Department Validation Tracers using the Environmental and Chart Review tools

-Developing and ensuring sustained compliance with corrective action plans

-Serving as a member of assigned committees/teams and reports regulatory compliance

Identify areas of vulnerability and assist department leaders in developing corrective action plans

Investigations Hospital-Acquired Conditions using evidence based criteria to determine if present on admission. Communicates Hospital-Acquired Condition findings to the providers for appropriate follow up

Performs education to nurses and medical staff on Hospital-Acquired Conditions and appropriate documentation requirements.

Infection Control Preventionist:

Oversees all infection control activities. Have understanding of TJC Infection Control standards. Plans, implements, evaluates and reports on infection control functions throughout the organization. Participates in hospital and medical staff committees as required. Educates staff on infection control principals. Establishes and implements infection control policies and procedures.

ESSENTIAL FUNCTIONS

Coordinates the development and evaluation of the organization's infection prevention and control strategies, policies, and planning.

Collects and performs statistical analysis, interpretation and dissemination of healthcare acquired infection data, including risk assessment, surveillance priorities, and outcomes analysis.

Monitors local, state and federal regulations and ensures compliance with accrediting and regulatory agencies' standards and requirements.

Assists with the development of educational resources and initiatives.

Monitors research and developments in the field of infection prevention and control to identify best practices.

Reports to: Director of Quality & Risk

Minimum education

 Associate?s degree in nursing - Required

Required Skills

Requires critical thinking skills, decisive judgment and the ability to work with minimal supervision. Must be able to work in a stressful environment and take appropriate action.

Licenses: Current Registered Nurse (RN) license to practice in the state of Alabama.

About Andalusia Health

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