In association with the Administrative Director, Quality, Compliance & Safety, and according to established policies and procedures, directs hospital-wide leadership in regulatory compliance and improvement, and infection control programs. Ensures compliance with internal and external standards and principles of medical safety. Responsible for on-going hospital readiness for accreditation. Collaborates to identify regulatory compliance improvement opportunities/priorities, develop regulatory compliance plans and follow through on implementation of plans to ensure accreditation and regulatory requirements are met. In collaboration with system regulatory leadership ensures audits and action plans, recommendations for improvement and updates are provided to regulatory governing bodies as deemed. Provides leadership and education to departments regarding regulatory compliance, process/performance measurements, monitoring and evaluation. In collaboration with the Corporate Director of Epidemiology, provides direct oversight for hospital-wide Infection Prevention and Hospital Epidemiology program staff. Collaborates with Occupational Health Services on a variety of functions including recommended immunizations and policies and procedures related to regulator mandates and infection control. Develops, monitors and revises functional processes in accordance with goals and objectives. Provides input into the development and revision of organizational structure for area. Approves personnel actions such as hires, fires, disciplines, etc. Ensures the timely completion of performance appraisals. Develops current to intermediate goals and measures for the department. Measures and assesses performance. As requested, assists in long-range goal development. Develops and monitors budget for area. Monitors activities for and ensures compliance with laws and government regulations. Responsible for DMC policies, as well as JC (Joint Commission) coordination and follow-up. As directed, implements external and internal audit recommendations. Ensures hospital departments achieve objectives for diversity of their suppliers. [BRASSRING IMPORT 9/27/16]
Qualifications: 1.Bachelors degree in Nursing. Masters degree in a health-related field or the equivalent combination of education and/or experience preferred. 2.Licensed to practice as a Registered Nurse in the State of Michigan. 3.Three to five years progressively more responsible experience. 4.Three years progressively more responsible management experience in an acute care facility with at least one year of frequent involvement with senior management, physicians and outside patient care providers. 5.Experience in the use of personal computers as well as knowledge of statistical or spreadsheet software tools. Job: Compliance Primary Location: Detroit, Michigan Facility: Detroit Medical Center Shared Services Job Type: Full-time Shift Type: Days
Employment practices will not be influenced or affected by an applicant’s or employee’s race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.