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 program requirements, and organizational policies. It interprets and communicates regulatory updates from agencies including CMS, MassHealth, DPH, The Joint Commission, and CDC, and maintains knowledge of standards affecting procedural care. The advisor coordinates regulatory readiness activities such as mock surveys, tracer activities, document reviews, and departmental assessments; maintains compliance records and evidence of corrective actions; and assists departmental leaders with regulatory surveys, accreditation visits, and external audits. The position makes clinical judgments based on evidence-based standards of care, review criteria, and nursing practice guidelines when applicable, and uses electronic health information imaging when appropriate. It also monitors applicable PRO/PM measures and Joint Commission DSC certification requirements and manages surgical registries, including BCBS total joint replacement and spine surgery registries.

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 amid 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 a focus on improving and promoting quality and monitoring one’s own work.
Exceptional communication skills, including conveying necessary 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 and certification standards, and organizational policies affecting procedural services.
Interpret and communicate relevant regulatory updates from CMS, MassHealth, DPH, The Joint Commission, CDC, and other applicable agencies.
Maintain current knowledge of regulatory standards related to 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/certification program requirements, including PRO/PM measures and Joint Commission DSC certifications.
Manage surgical-related registries, including BCBS total joint replacement and spine surgery registries.