The Quality Regulatory & Performance Improvement (PI) Specialist performs a variety of functions under the Quality Department scope of work with primary focus on playing a key role in monitoring regulatory standards, preparing for accreditation surveys, driving performance improvement initiatives and contributing to the provision of high-quality patient care. The Regulatory & PI specialist would serve as a resource to hospital and medical staff departments to ensure the compliance with regulatory agency standards.  Play an active role in planning and implementation of compliance activities for accreditation and/or regulatory agencies requirements, including Joint Commission and CMS. This position would collect, analyze, and present data related to ongoing regulatory compliance efforts.

1. Serves as PI resource to assigned PI Teams and facilitates use of performance improvement methods to improve quality and regulatory metrics.
2. Conducts concurrent and retrospective Quality case reviews as assigned.
3. Conducts assigned screening and measurement activities including data collection and analysis.
4. Provides expertise in defined quality and regulatory related topics to drive process improvement and change management
5. Identifies and defines problems, collect data, establish facts and draw valid conclusions
6. Provides both formal and informal training relating to performance improvement and regulatory compliance.
7. Engages department teams to maintain for system and regulatory requirements.
8. Generates reports and communicates results and activities to administration, medical staff and other internal and external parties to support organizational improvement initiatives.
9. Participates in collection, analysis and data reporting related to ongoing compliance efforts.
10. Facilitates and actively participates in quality improvement teams
11. Self – directs and motivates to solve problems
12. Demonstrates strong knowledge of concurrent Quality Improvement methodologies and performance measures (i.e. PDSA, chart and graph interpretation)
13. Stays up to date on changes to Joint Commission Standards and CMS Regulations, interpreting and disseminating relevant information as needed.
14. Responsible for assessing, monitoring, and recommending activities and educational opportunities to maintain compliance with accreditation and/or regulatory standards.
15. Collaborates with interdisciplinary teams, including nursing, medical staff, quality improvement, and administration, to address compliance issues and drive organizational readiness for regulatory surveys and drive organizational readiness for accreditation and certification surveys.
16. Through regular audits, identifies areas for improvement and facilitate corrective actions as needed.
17. Actively participates in performance improvement initiatives and interdisciplinary hospital committees to promote high quality patient care and ensuring policy or process changes align with regulatory standards.

DCH Standards:

• Maintains performance, patient and employee satisfaction and financial standards as outlined in the performance evaluation.
• Performs compliance requirements as outlined in the Employee Handbook
• Must adhere to the DCH Behavioral Standards including creating positive relationships with patients/families, coworkers, colleagues and with self.
• Performs essential job functions in a manner that ensures the safety of patients, visitors and employees.
• Identifies and reduces unsafe practices that may result in harm to patients, visitors and employees.
• Recognizes and takes appropriate action to reduce risks and hazards to promote safety for patients, visitors and employees.
• Requires use of electronic mail, time and attendance software, learning management software and intranet.
• Must adhere to all DCH Health System policies and procedures.
• All other duties as assigned.

• Registered Nurse with current licensure for the state of Alabama
• Minimum of three years’ experience in an acute care facility.
• Clinical background that would facilitate assessment of patient care data for coordination of quality projects.
• Ability to work independently, and manage multiple projects, with strong prioritizing skills
• Familiarity with Joint Commission and CMS standards and terminology
• Basic knowledge of computers and office productivity software.
• Basic knowledge of data analysis.
• Ability to communicate effectively.
• Must be able to read, write legibly, speak and comprehend English.
• Ability to maintain confidentiality.
• Demonstrates independent skills, use of electronic emails, be a team player in relationship to working with others in groups and teams.
• Able to prioritize, organize and accomplish work.
• Keeping updated on technology and applying knowledge as applicable.
• Expected to have the ability to read, analyze and interpret general business periodicals, professional journals, technical procedures or governmental regulations