About City of Hope
City of Hope is an independent biomedical research and treatment organization for cancer, diabetes and other life-threatening diseases.
Founded in 1913, City of Hope is a leader in bone marrow transplantation and immunotherapy such as CAR T cell therapy. City of Hope's translational research and personalized treatment protocols advance care throughout the world. Human synthetic insulin, monoclonal antibodies and numerous breakthrough cancer drugs are based on technology developed at the institution. AccessHope™, a subsidiary launched in 2019 serves employers and their health care partners by providing access to City of Hope's specialized cancer expertise.
A National Cancer Institute-designated comprehensive cancer center and a founding member of the National Comprehensive Cancer Network, City of Hope is ranked among the nation's "Best Hospitals" in cancer by U.S. News & World Report and received Magnet Recognition from the American Nurses Credentialing Center. Its main campus is located near Los Angeles, with additional locations throughout Southern California and in Arizona.City of Hope's commitment to Diversity, Equity and Inclusion
We believe diversity, equity and inclusion is key in serving our mission to provide compassionate patient care, drive innovative discovery, and advance vital education focused on eliminating cancer and diabetes in all of our communities. Our commitment to Diversity, Equity and Inclusion ensures we bring the full range of skills, perspectives, cultural backgrounds and experiences to our work -- and that our teams align with the people we serve in order to build trust and understanding. We are dedicated to fostering a community that embraces diversity - in ideas, backgrounds and perspectives; this is reflected in our work and represented in our people.Position Summary
The Regulatory, Accreditation and Risk Coordinator is accountable to and works closely with the Clinical Risk Manager, Medical Staff, Nursing and Ancillary departments to provide expertise and coordination for the Enterprise regulatory, accreditation and clinical risk programs according to the goals as set by the organization. Works in collaboration with the Clinical Risk Manager in the development, planning, coordination and operationalization of a systematic program designed to promote compliance and high reliability. Analyzes clinical risk management data, develops and conducts clinical risk educational programs, complying with clinical risk management related standards by Joint Commission and other regulatory agencies. Responsible to effect change through ensuring compliance with regulatory and accreditation standards, promoting patient safety, enhancing quality care and minimizing clinical loss to protect the assets of the organization. Drives process improvements with multidisciplinary teams to achieve the institutions' mission and vision for the highest level of safety, speed, and efficiency for patient care. Key Responsibilities include:
The Regulatory and Risk Coordinator is accountable to the Clinical Risk Manager:
- Supports the day to day needs of the clinical risk program for Enterprise operations, departments and services.
- Assists the Clinical Risk Manager in reviews and revisions of the clinical risk management program at least biannually.
- Coordinates regulatory activities including review of events for potential external reporting, reporting when indicated, ensures a robust review and investigation with plan of correction and follow-up with external agencies as needed.
- Coordinates accreditation activities to ensure ongoing survey readiness for Joint Commission, ACOS CoC and other surveys as needed.
- Manages the incident reporting system. Collects, reviews, evaluates, and reports on events and incidents. Performs statistical analysis and trending of events and ensure proper visualization of data.
- Reports trended data and mitigation actions to the Clinical Risk Manager and as assigned, the appropriate committees, departments and individuals.
- Assists in the investigation of serious events as assigned. Assists with communication and documentation of errors or serious events in accordance with legal requirements and/or accreditation standards.
- Leads Failure Mode Effect Analyses and Root Cause Analyses investigations and develops action oriented recommendations to correct and/or eliminate deficiencies that may adversely affect patients, visitors and staff.
- Assists with annual proactive risk assessments to identify opportunities to improve reliability in processes and reduce risk, including an FMEA.
- Coordinates the product recall program (except for pharmaceuticals and blood products) and ensure robust participation to reduce the likelihood that problem products are utilized in the clinical setting.
- Educates and assists in assessing clinical areas for exposures to loss and unsafe processes and conditions.
- Participates in Safe Patient Team and other committees as needed to communicate findings, recommendations, actions and results.
- Ensures compliance is with various codes, laws, rules and regulations concerning patient care/safety, including those mandates by state and federal agencies.
- Reviews patient complaints and works with the Manager of Patient Advocacy to offer solutions to patient grievances when assigned.
- Collaborates with the Quality and Regulatory staff in matters related to regulatory compliance, policy planning and implementation.
Regulatory & Accreditation Activities
- Maintains knowledge of TJC standards, CDPH regulations, and other regulations an accreditation standards as needed.
- Ensures processes, programs and policies are in place to continually improve regulatory and accreditation compliance and quality care.
- Coordinates annual mock surveys, regulatory visits, and assigned accreditation surveys.
- Chairs and coordinates the activities of the Survey Readiness team.
- Coordinates the Tracer Program.
- Oversees the JC AMP tool program and ensures annual review of standards.
- Provides education programs to all current and future employees, physicians and leadership to advise them of their responsibilities, obligations, and part in the facility's accreditation activities.
- In collaboration with the Clinical Risk Manager, identifies, investigates significant events and reports Never and Unusual Occurrences to CDPH per policy.
- Reports CCRT22 flex requests to CDPH per policy.
- Maintains the EOLOA log and restraint log as mandated by CDPH
- Coordinates annual tissue license renewal for the medical center andCalifornia Children's' Services (CCS) renewals.
- Performs proactive gap analyses on the Joint Commission sentinel event alerts; the CDPH immediate jeopardy events; and other public reported clinical risk issues.
Communication of Strategic Information
- Identify and evaluate performance of meaningful clinical risk metrics
- Communicates hospital performance, risk issues, accreditation status and risks and regulatory compliance as requested.
- Communicates with relevant parties and the Policy and Procedure Manager regarding integration of findings, regulations and suggestion to improve policy and procedures.
- Performs benchmarking of performance against industry leaders.
- Provides education on accreditation readiness, regulatory compliance, high reliability, just culture and clinical risk information throughout the organization.
- Visits offsite locations at least annually to meet and educate staff.
- Assists in the implementation an Enterprise wide program for both clinical loss prevention and loss control, and a comprehensive orientation program. Those programs will be directed to all current and future employees, members of the board, and physicians to advise them of their responsibilities, obligations, and part in the facility's risk management program.
- Assist the Clinical Risk Manager in the development and implementation of a comprehensive Clinical Risk Management Program
- Assists in the review and revision of the Risk Management Program at least biannually.
- Ensures there is a functional, robust Enterprise event reporting system that is accessible to all staff, usable, and provides for timely identification of issues, tracking and trending.
- Reviews events/TIPS routinely to track and trend, ensure adequate follow-up and take further action when indicated by type of event.
- Adds, deletes users, and orient staff to TIPS system.
- Coordinates and ensure robust participation in the ECRI Product Recall Program (excluding pharmaceutical and blood products that are handled by their respective departments).
- Serves as FMEA consultant/process expert. Ensures an annual FMEA is completed.
- Assists in ensuing a formal proactive risk identification annually both on campus and at the Community sites.
- Collaborates with Patient Advocacy on Grievance reviews as assigned.
- Investigates and crafts responses to insurance complaints
- Based on a systematic and statistical analysis, creates, communicates and executes a strategy for clinical risk improvements.
- Supports the implementation of evidenced based state and national clinical risk/patient safety initiatives.
- Active participant in promoting a High Reliability/Culture of Safety.
Follows established City of Hope and department policies, procedures, objectives, performance improvement, attendance, safety, environmental, and infection control guidelines, including adherence to the workplace Code of Conduct and Compliance Plan. Practices a high level of integrity and honesty in maintaining confidentiality.
Performs other related duties as assigned or requested.Basic education, experience and skills required for consideration:
- BA, BSN or BS degree in Healthcare/Biological Science. Experience may substitute for educational requirements.
- 3 years of clinical acute care experience
- 2 years of experience in risk or regulatory role
Preferred education experience and skills:
- Healthcare Accreditation Certified Professional (HACP from CIHQ) required within one year of hire.
- Masters in Nursing or related healthcare field
- Certified Professional in Healthcare Quality (CPHQ) certification
- Certified Professional in Healthcare Risk Management (CPHRM) certification
- Healthcare Accreditation Certified Professional (HACP from CIHQ)
- Lean certification
- RN Licensure
- Risk and Regulatory Management activities in a clinical setting.
- As a condition of employment, City of Hope requires staff to comply with all state and federal vaccination mandates.
City of Hope is committed to creating a diverse environment and is proud to be an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, sex, sexual orientation, gender identity, age, status as a protected veteran, or status as a qualified individual with disability.