The Accreditation, Regulatory & Patient Safety Officer oversees and coordinates all aspects of accreditation, regulatory, hospital licensure compliance, and patient safety program for Deaconess Illinois facilities. Partners with leadership and subject matter experts to ensure accreditation readiness through operational committees, communication, facilitation, and project management.
What You'll Do
- Communicate about accreditation/regulatory requirements, implications to the healthcare environment and strategies to reliably achieve compliance.
- Lead accreditation/regulatory efforts to ensure continual organizational compliance and ongoing readiness.
- Identify opportunities for improvements based on evidence-based practices in regulatory and accreditation compliance, analysis of internal and external compliance/risk assessments and findings from regulatory authorities.
- Provide and manage through facility contacts, the structures for ongoing compliance, survey processes, applicable state department of health licensure requirements and CMS conditions of participation.
Required: Certifications/Licenses/Experience:
- Active Registered Nurse (RN) in applicable state other compact licensure state (if applicable)
- Minimum of three years in Patient Safety, Quality, Accreditation, or Regulatory field
- Bachelor's Degree in nursing or related field
Preferred Certification/License/Experience:
- 2-3 years of related experience in the acute care setting
- ICU or ER experience
- CPHQ certification
- MSN