RN Program Manager, Accreditation and Patient Safety
Franciscan System Services
This is a Full-time position in Seattle, WA posted December 30, 2021.
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 5,000 physicians and providers. Together, we are empowered to make an even greater impact on the health and well-being of our communities.
CHI Franciscan and Virginia Mason are now united to build the future of patient-centered care across the Pacific Northwest. That means a seamlessly connected system offering quality care close to home. From basic health needs to the most complex, highly specialized care, our patients can count on us to meet their needs with convenient access to the region’s most prestigious experts and innovative treatments and technologies.
As a part of our organization, we currently offer the following benefits:
- Competitive starting wages (DOE) and training to grow within the company
- Paid Time Off (PTO)
- Health/Dental/Vision Insurance
- Flexible health spending accounts (FSA)
- Matching 401(k) and 457(b) Retirement Programs
- Tuition Assistance for career growth and development
- Care@Work premium account for additional support with children, pets, dependent adults, and household needs
- Employee Assistance Program (EAP) for you and your family
- Voluntary Protection: Group Accident, Critical Illness, and Identify Theft
- Adoption Assistance
- Wellness Program
Responsibilities
Job Summary:
The position provides operational support and overall coordination for the strategic implementation of Patient Safety and Accreditation and Licensing programs. The incumbent is responsible for all facets of patient safety are identified, and coordinated into a comprehensive plan. The role is also accountable for keeping knowledge and skills current in assigned subject area through self-education, community networking and professional organization offerings.
Other key duties include policy and procedure implementation; survey preparation; survey management and follow-up; assessment of standards compliance and reporting of vulnerabilities to key stakeholders; conducting training in response to identified or potential deficiencies to management, educators and staff.
Essential Job Functions:
- 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 Virginia Mason Franciscan Health (VMFH) annual intra-cycle monitoring of compliance with Joint Commission standards 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 of Quality Division, Informatics, Continuous Performance Excellence (CPE), organized Medical Staff, and Education Services to ensure communication and implementation of system quality improvement and safety plan
- Assists in review/trending of incident report information and provides quality information for internal quarterly review and ongoing physician performance evaluation. Provides guidance and coaching to management aimed at achieving a state of continuous readiness surrounding licensure, accreditation and certification programs as well as ensuring ongoing compliance with state and federal rules and regulations.
- Performs related duties as required.
Qualifications
Education/Work Experience Requirements:
Bachelor’s degree in a healthcare related field and 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.
Licensure/Certification:
Current licensure as a Registered Nurse by the Washington State Nursing Commission.
