Compliance Specialist

Mass General BrighamBoston, MA
Onsite

About The Position

The General Hospital Corporation Mass General Brigham is a not-for-profit organization that supports patient care, research, teaching, and community service, striving to provide exceptional care and drive groundbreaking medical discoveries through high-performing teams. The Compliance Specialist role is responsible for supporting the implementation and maintenance of the hospital's compliance program, which includes conducting audits, providing training, monitoring compliance activities, and assisting with investigations to foster ethical conduct and mitigate compliance risks. This position does not involve direct patient care. The Compliance Specialist reports to the Clinical Compliance Manager, Central Sterile Processing & Supply (CSPS), and receives direction from the Director of Operational Alignment & High Reliability. The core responsibility involves the independent acquisition, analysis, interpretation, and reporting of data to support the CSPS Department and the High-Level Disinfection and Sterilization Program (HLDS), along with its subcommittees, to achieve established goals and program outcomes. The incumbent will engage with various business leaders across the organization, including Physicians, Finance, Sterile Processing Nursing, Administrative Directors and Managers, and PHS resources, to execute initiatives. The role requires the ability to work both independently and collaboratively to locate and validate data, identify data requirements, and communicate data specifications to team members and leaders. The Project Specialist will also manage resources associated with these projects and is expected to collaborate with the Sterile Processing Department, intermittently supporting projects involving Procedural Services and MGB initiatives.

Requirements

  • Bachelor's Degree Related Field of Study required
  • Experience in compliance, legal, or a related field. 2-3 years required
  • Knowledge of relevant laws and regulations applicable to the industry or sector (e.g., financial, healthcare, technology).
  • Familiarity with compliance frameworks and best practices.
  • Excellent attention to detail and analytical skills.
  • Strong written and verbal communication skills.
  • Ability to work collaboratively and independently as needed.
  • Proficiency in using Microsoft Office and other relevant software applications.

Responsibilities

  • Assist in developing, implementing, and maintaining the hospital's compliance program, including policies, procedures, and protocols.
  • Conduct periodic audits of hospital departments and processes to assess compliance with policies and identify areas for improvement.
  • Assist departments in understanding and implementing compliance policies, ensuring consistency and adherence throughout the organization.
  • Support the reporting and investigation of compliance-related incidents and potential violations.
  • Assist in monitoring compliance activities, analyzing data, and preparing compliance reports for presentation to senior management and relevant committees.
  • Participate in compliance committee meetings, providing updates on compliance activities and contributing to discussions on compliance matters.
  • Act as a critical participant in the evolution and continued development and implementation of the High-Level Disinfection and Sterilization Program.
  • Participates in the hospital-wide Interdisciplinary Tracer Program to learn, define, and evaluate reprocessing practices in all active reprocessing areas; develop a deep familiarity with AAMI standards over time.
  • Maintain documentation systems as processes evolve and become more standardized; assigns department representatives for ongoing Tracer participation.
  • Implements unified weekly and monthly reports describing the program's progress to leadership and appropriate governance committees.
  • Attends the High-Level Disinfection and Sterilization Task Force meetings and associated subcommittees, developing presentations, writing minutes, and coordinating follow-up on action items resulting from the meetings.
  • Closely adheres to project plans, charters and clinical support resources to ensure objectives are met.
  • Ensures assessments are cataloged for all active reprocessing locations.
  • Develops and implements comprehensive unit-specific remediation plans that may include the following elements, employee training, workflow development, inventory assessment and conversion, and design/construction. Remediation plans aim to reduce the breadth of reprocessing locations and process variability to ensure sustainable best practices are in place.
  • Practices sound risk management throughout the project process.
  • Gathers and compiles documentation of metrics and data sources, routine, ad hoc reporting to facilitate replication.
  • Completes cross-institutional project initiatives and informs leadership of best practices that may be adopted from other hospital departments or procedural areas.
  • Supports the MGB and Procedural Services Committee to support the strategic alignment of the department, hospital, and systems-based sterile processing functions and workstreams.
  • Leads the implementation of the information system, SPDR, to manage, track, and bill for reprocessing activities performed by SPD on behalf of the PO.
  • Provide training to other data analysts working within the Sterile Processing team.
  • Develop a deep familiarity with EPIC and SPM instrument tracking software to appreciate underused capabilities for structuring improvements in departmental workflows; leverages data visualization tools to build operational dashboards.
  • Develop and introduce new and unique ways to improve data delivery, operations and to create new opportunities.
  • Develop reporting/analytic solutions, but also be able to assess/determine business impact, draw meaningful conclusions, and make recommendations for actions.

Benefits

  • In addition to competitive base pay, we offer comprehensive benefits, career advancement opportunities, differentials, premiums and bonuses as applicable and recognition programs designed to celebrate your contributions and support your professional growth.
© 2024 Teal Labs, Inc
Privacy PolicyTerms of Service