Director Infection Prevention & Regulatory Compliance

Employee Type

Regular

Work Shift

Day - 12 hour shift (United States of America)

Join Team Tidelands and help people live better lives through better health!

Position Summary :

Maintains accreditation by monitoring compliance to all required standards and conditions. Reducing risk for the multi-hospital organization by improving patient safety requires the effective leadership and direction of all necessary initiatives with the board of trustees, senior leadership, hospital leaders, physician partners, all employees, as well as patients and families. The Patient Safety Officer (PSO) is responsible for directing risk reduction efforts for all Tidelands Health services. This requires the systematic direction of effective, reliable care practices, and developing an appropriate institutional patient safety culture, risk/error analysis, occurrence reporting, accreditation readiness, infections prevention, policy and clinical contract management, and all education and improvement initiatives that are required for each.

Effective leadership in patient safety programs, accreditation / regulatory readiness, infection prevention / required government reporting, patient safety data analysis, just culture, change management and continuous performance improvement methodology will be required to ensure Tidelands Health becomes a High Reliable Organization. An important aspect of the PSO is the ability to work collegially and collaboratively with a large number of groups and individuals on multiple system initiative across the enterprise.

QUALIFICATIONS

Experience :

• At least seven (7) years of leadership experience in strategic planning, program development and operations for reducing risk and avoidable harm, infection control and regulatory compliance in a complex medical environment by working with the board of trustees, administration, physicians, employees, patients, visitors and community.

• At least seven (7) years leadership experience in regulatory / accreditation compliance for all of the following: Center for Medicare/Medicaid Services (CMS), The Joint Commission or comparable agency, the state's department of health and environmental control for both inpatient, ambulatory services and specific disease center of excellence.

• At least five (5) years of leadership experience in infection prevention including directing all federally required publicly reported data on the reduction of healthcare-associated infections.

• At least five (5) years of leadership experience in healthcare departmental operations and financial management.

• Minimum five (5) years clinical experience required.

Education :

• Bachelor's degree in nursing, pharmacy, advanced provider (nurse practitioner or physician assistant), medical degree (M.D. or D.O), or related clinical specialty area with 10+ years health care experience required.

• Master's degree in business / healthcare administration preferred or more than ten (10) years' additional experience successfully leading a healthcare accreditation / patient safety program.

Licensure/Certification :

• SC license required in nursing, pharmacy, advanced provider (nurse practitioner or physician assistant) or medical examiners / physician required.

• Specific healthcare accreditation / regulatory compliance training, required.

• Just Culture certification, preferred.

• Lean / Six Sigma certification, preferred.

• Specific patient safety or risk training, preferred.

• Excellent interpersonal, communication, presentation, conflict resolution and team facilitation skills related to many levels in the organization, including board of trustees, physicians, executives, managers, front-line staff, patients, visitors and community.

• Computer skills, to include data entry, spreadsheets, graphics, information systems.

• Ability to collect, analyze and disseminate data, including financial and statistical data

• Knowledge of performance improvement tools, and the ability to use them effectively

• Experience working with clinical outcomes data systems and resource management

• Ability to set goals and work independently and efficiently with minimal supervision; ability to prioritize fluctuating workload and times to meet position demands

• Ability to work in a fast-paced environment and manage multiple meetings and projects

• Knowledge of regulatory standards including Joint Commission, Medicare (CMS) and Title 22 (state) requirements

• Written and oral communication / education including but not limited to the publication of the patient safety e-newsletter.

• Capable of exercising sound judgment and making independent decisions.

• Ability to adapt to a complex organizational environment.

Physical Requirements : Light Physical Agility Test (PAT) Rating

While performing the duties of this job, the employee is frequently (activity or condition exists from 1/3 to 2/3 of the time) required to stand, sit, and walk; frequently to use hands, fingers; and frequently to talk or hear. The employee must exert up to 15 pounds of force occasionally (activity or condition exists up to 1/3 of the time), and/or up to 5 pounds of force frequently, and/or a negligible amount of force constantly to move objects.

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.

Tidelands Health is an equal opportunity employer (EOE). Tidelands Health does not discriminate against employees or applicants for employment on the basis of race, color, creed, religion, age, national origin, disability, marital status, veteran status, gender, genetic information, familial status, or any other legally protected status.