About City of Hope

City of Hope's mission is to deliver the cures of tomorrow to the people who need them today. Founded in 1913,City of Hopehas grown into one of the largest cancer research and treatment organizations in the U.S. and one of the leading research centers for diabetes and other life-threatening illnesses.City of Hope research has been the basis fornumerous breakthrough cancer medicines, as well as human synthetic insulin and monoclonal antibodies. With an independent, National Cancer Institute-designated comprehensive cancer center at its core,City of Hope brings a uniquely integrated model to patients spanning cancer care, research and development, academics and training, and innovation initiatives. City of Hope’s growing national system includes its Los Angeles campus, a network of clinical care locations across Southern California, a new cancer center in Orange County, California, andtreatment facilitiesin Atlanta, Chicago and Phoenix.City of Hope’s affiliated family of organizations includesTranslational Genomics Research InstituteandAccessHope^TM.For more information about City of Hope, follow us onFacebook,Twitter,YouTube,InstagramandLinkedIn.

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

This role acts as a clinical expert for risk and regulatory management. The position supports the Enterprise by providing data, analysis, best practice and background information to the organization and the Medical Departments, for performance improvement activities, quality reports, and facilitates response to insurance grievances for the enterprise. The Risk and Regulatory Management Specialists (RRMIS) leads regulatory, risk assessments, and accreditation activities. This position is designed to assist the enterprise in defining, measuring, analyzing, and applying data to mitigate risk, make quality improvements and comply with accreditation standards and/or regulations. The RRMIS is an expert resource in process and outcome measurement, analysis, and performance improvement including concepts and techniques, evidenced based practices, relevant legislation, accreditation standards, medical staff bylaw/rules and regulations, and policies/procedures. The position requires knowledge of lean/six sigma process improvement tools, facilitative leadership, change management, risk management concepts, regulatory and licensing standards.

Key Responsibilities include:

Team Leading/Facilitation

• Coordinates and leads discrete quality improvement teams to address system issues identified related to adverse events, proactive risk assessments and regulations impacting process.
• Collaborates with staff, administrators and/or the physician liaison for each team in the development of the agendas; tracks the actions and assures timely follow up on actions.

Event Investigation, Mitigation and Correction

• Supports event reporting and peer review for campus and external community clinics.
• Facilitates root cause analyses and other investigative activities needed to refine and modify policies and procedures and/or processes to improve the quality of patient care.
• Follows-up on quality activities such as case/sentinel event reviews to make sure appropriate changes have taken place.

Quality/Metric and Peer Data Collection and Reporting

• Obtains, reviews and analyzes clinical data through review of the in-patient and out-patient medical record and data reports from numerous sources to gather data for OPPE, peer review, other case review, quarterly quality reports, special projects, performance improvement and other quality metrics chosen by the organization or mandated by external agencies;
• Participates in observational activities (e.g. nursing studies, policy adherence) to collect needed data.
• Collaborates with Quality Analytics, Biostatistics and other departments to develop processes to ensure accurate, timely, consistent access to relevant data.
• Presents data in a meaningful and useful manner.
• Attends the applicable medical staff committees for quality report and event review and is an active participant at Safe Medication Team, Safe Patient Leadership Team Committee, Quality, Assurance and Improvement (QA&I)

Performance Improvement

• Acts as an expert internal consultant for performance improvement activities including the Performance Excellence Program.
• Uses data in recommending solutions to issues.
• Utilizes change theory and systems analysis to impact improvements in practice or standards compliance.
• Models behaviors that support improvement activities including critical thinking and multiple strategies identification.
• Coaches and supports staff in using performance improvement strategies in their work.
• Supports physicians and staff to make recommendations and identify performance improvement opportunities based on data.
• Incorporates improvement strategies to enhance quality of patient care.

Accreditation and Survey Readiness

• Active member of the CALS Committee.
• Coordinate monthly tracers with team leads and collects all data related to tracer activities for corrective action.
• During actual surveys (TJC, CDPH, CAP) act as scribes and escortsto the survey team and staff, the command center.

Regulatory/Compliance

• Demonstrates knowledge of regulatory bodies and standards as they apply to their areas of responsibility
• Identifies the need to develop or revise policies/procedures as they relate to quality work.
• Keeps the medical staff and other committees informed on the metric teams, and solicit ongoing input to drive improvements.
• Demonstrates understanding and support the Code of Conduct.

Education and Teaching

• Supports education that impacts quality of patient care, reduces risk, and promotes regulatory readiness.
• Provides management with information regarding the Clinical Quality and Healthcare Improvement Program.
• Assists with education of staff as requested
• Attends mandatory and non-mandatory medical center, divisional, and departmental education activities

Collaboration and Teamwork

• Supports and facilitates positive working relationships within the department, between individual employees and other healthcare providers.
• Supports team working relationships within assigned department(s) between all levels of personnel
• Serves as a role model to staff and other by demonstrating collaborative working relationships with employees and all patient care departments
• Facilitates positive relationships for those requesting departmental assistance
• Maintains effective open communication between departments in order to assure timely and quality care for patients/families
• Facilitates and support working relationships with patients, families, or other health care providers
• Identifies and participates in the resolution of breaks in communication between parties
• Promotes positive interpersonal relationships and demonstrates effective communication methods
• Maintains awareness of and follows appropriate lines of communication
• Facilitates staff in utilization of appropriate lines of communication

Professional Development

• Maintains professional code of ethics and scope of practice by adhering to national, institutional, and divisional standards, policies, procedures, and protocols.
• Participates in appropriate professional organizations
• Maintains current licensure and certifications
• Demonstrates accountability and responsibility for own professional practice
• Attends organization wide and medical staff committees as assigned
• Attends at least 80% of assigned meetings
• Maintains awareness of own developmental needs
• Shares new knowledge with other member of the staff and colleagues
• Incorporates knowledge and skills into professional practice and program development.
• Utilizes networking to obtain relevant information in the understanding and application of relevant practice and regulatory standards

Performs other duties as assigned

• Masters Degree in Nursing or BSN with masters in related/complementary field required.Experience may substitute for minimum education requirements.
• Three years experience in clinical nursing and/or quality, risk and regulatory activities
• Thorough knowledge of Joint Commission, Title 22, CMS Conditions of Participation and other regulatory agencies

Required Certification/Licensure:

• Current California RN license
• Specialty certification (CPHQ/HACP) preferred

Additional Information:

• Job Status: Full-time, exempt
• As a condition of employment, City of Hope requires staff to comply with all state and federal vaccination mandates.