Quality Patient & Safety Advisor – Regulatory Compliance

Cape Cod Healthcare•Hyannis, MA

About The Position

The Quality Patient & Safety Advisor supports regulatory compliance and readiness for procedural services. The role monitors compliance with applicable regulatory requirements, accreditation standards, certification programs, and organizational policies; interprets and communicates relevant regulatory updates; and coordinates readiness activities such as mock surveys, tracer activities, document reviews, and departmental assessments. The advisor maintains compliance records and corrective-action evidence and assists departmental leaders with regulatory surveys, accreditation visits, and external audits. The position requires clinical judgment based on evidence-based standards of care, review criteria, and nursing practice guidelines when applicable. It also includes using electronic health information imaging when appropriate, monitoring compliance with PRO/PM measures and Joint Commission DSC certifications, and managing surgical registries related to BCBS total joint replacement and spine surgery.

Requirements

Graduate of a school of nursing.
Bachelor of Science in Nursing (BSN).
Three years of prior nursing experience in perioperative or procedural areas.
Ability to work independently, prioritize work activities, and use time efficiently.
Ability to maintain confidentiality.
Ability to demonstrate and promote a positive team-oriented environment.
Ability to stay focused and concentrate under normal or heavy distractions.
Ability to work well under pressure and stressful conditions.
Ability to manage change, delays, or unexpected events appropriately.
Strong knowledge of medical terminology, anatomy and physiology, medications, and laboratory values.
Ability to operate a general computer, fax, copier, scanner, and telephone.
Knowledge of multiple software programs, including Microsoft Word, Outlook, Excel, and the Internet.
Excellent English usage, grammar, punctuation, and style skills.
Ability to follow instructions and respond accurately to upper management’s directions.
Accuracy and thoroughness, with the ability to seek improvements, promote quality, and monitor work to ensure quality standards are met.
Exceptional communication skills, including conveying information accurately, listening effectively, and asking questions when clarification is needed.
Ability to work for long periods of time on a computer.

Responsibilities

Monitor compliance with applicable regulatory requirements, accreditation standards, and organizational policies affecting procedural services.
Interpret and communicate relevant regulatory updates from CMS, Mass Health, DPH, The Joint Commission, CDC, and other applicable agencies.
Maintain current knowledge of regulatory standards related to procedural services, including pre-procedure assessments, informed consent, patient identification, time-outs, medication management, infection prevention, discharge planning, and medical record documentation.
Coordinate regulatory readiness activities, including mock surveys, tracer activities, document reviews, and departmental assessments.
Maintain regulatory compliance records, supporting documentation, and evidence of corrective actions.
Assist departmental leaders in preparing for regulatory surveys, accreditation visits, and external audits.
Make clinical judgments based on evidence-based standards of care, review criteria, and nursing practice guidelines when applicable.
Utilize electronic health information imaging when appropriate.
Monitor compliance with applicable regulatory and accreditation or certification program requirements, including PRO/PM measures and Joint Commission DSC certifications.
Manage surgical-related registries, including BCBS registries for total joint replacement and spine surgery.