Accreditation and Patient Safety Specialist

The RN Clinical Accreditation and Patient Safety Specialist plays a crucial role in supporting Systemwide Clinical Compliance and Regulatory Services by implementing Cone Health's Accreditation Readiness Plan and Patient Safety Plan and fostering a culture of safety. This position collaborates closely with physicians, nurses, and other clinical and non-clinical leaders to evaluate and navigate the regulatory and patient safety environment, both internally and externally.

Essential Job Function:

• The RN Clinical Accreditation and Patient Safety Specialist plays a crucial role in supporting Systemwide Clinical Compliance and Regulatory Services by implementing Cone Health's Accreditation Readiness Plan and Patient Safety Plan and fostering a culture of safety.
• This position collaborates closely with physicians, nurses, and other clinical and non-clinical leaders to evaluate and navigate the regulatory and patient safety environment, both internally and externally.
• Essential Job Functions: Accreditation Preparedness: Ensure compliance with healthcare accreditation standards, including those set by The Joint Commission (TJC), Centers for Medicare and Medicaid Services (CMS), and the North Carolina Division of Health Services Regulation (NCDHSR).
• Support organizational responses, develop action plans, and manage follow-up communications with external regulatory agencies.
• Patient Safety: Serve as the principal investigator for patient safety event investigations within the assigned area, including conducting root cause and common cause analyses.
• Identify and accurately interpret significant trends and patterns in patient safety and adverse events.
• Quality Improvement: Lead quality and process improvement projects focused on enhancing patient care and safety.
• Leadership Partners: Serve as a liaison with executive leaders to foster culture of safety, partnering with leaders during crisis to provide guidance to promote adherence to regulatory bodies and agencies.
• Data Analysis: Regularly review trends and findings from the electronic patient safety reporting system to identify vulnerabilities.
• Collaborate with data analytics team members to proficiently analyze data and integrate findings with knowledge of other patient safety events, focusing on departmental and organizational improvement initiatives.
• Identify system failures related to adverse events and work with clinical teams and hospital leaders to plan improvements in patient care and safety.
• Lead clinical teams in developing and implementing practice and system changes designed to prevent errors, improve clinical care, and enhance patient safety.
• Additionally, collect and monitor compliance with external regulatory agency action plans.
• Education and Training: Provides education and training to staff on accreditation standards, patient safety protocols, and quality improvement methodologies.
• Performs other duties as assigned.

Education:

• Required: Bachelor's of Science in Nursing (BSN).

Experience:

• Experience: Minimum of 3 years of clinical nursing experience, preferably in hospital setting. Experience in quality improvement, patient safety, or accreditation is highly desirable.

Licensure/Certification/Listing:

• Required: RN | Registered Nurse licensed in North Carolina or a Compact state. Certifications: Certification in Healthcare Quality (CPHQ) or Patient Safety (CPPS) preferred.