NURSING QUALITY & REGULATORY COMPLIANCE MANAGER

About Us:

At Sinai Chicago, we take health care personally. Excellence in health care is about more than just medicine, technology, tests and treatments, it is about really caring for people with dignity and respect. That's what we do. We are dedicated to providing the best care to meet the needs of people, for our community, for our patients and for you.

Position Purpose:

The Nursing Quality and Regulatory Compliance Manager is responsible for enhancing the clinical quality and outcomes of Nursing practice using clinical data and project planning, implementation, and evaluation by applying evidenced-based best practices throughout Sinai Chicago. In addition, this role is responsible for developing systems and processes, which ensure continual Nursing survey readiness and regulatory compliance. The Nursing Quality and Regulatory Compliance Manager assesses, plans, organizes, directs, and evaluates overall Nursing quality and regulatory compliance initiatives at the unit, divisional, departmental and system level. The role also collaborates with Nursing leadership, Nursing staff and other patient care related services, as well as those in Quality/Performance Improvement roles to enhance the quality of Nursing practice using clinical data and the application of evidence-based practice. The Nursing Quality and Regulatory Compliance Manager has the specific responsibility for providing leadership and direction in overall Nursing quality and regulatory compliance.

Key Job Activities:

• Plans, coordinates, implements, and evaluates programs provided by Sinai Chicago relative to quality improvement and regulatory compliance
• Utilizes various assessments, tools, and data, identify gaps in compliance from a quality and regulatory compliance perspective in the Department of Nursing
• Provides oversight of the Nursing Quality data collection and submission to the Nursing Database of Nursing Quality Indicators (NDNQI) for benchmarking purposes and develop actions plans based on NDNQI reports and areas of opportunity
• Partner with Nursing Education to develop learning activities related to Nursing Quality improvement and regulatory standards
• Reports at the system, divisional and departmental level survey readiness findings, and action planning to ensure compliance
• Creates structure and processes to ensure optimal quality and compliant Nursing performance
• Partners with various service lines, departments, and leaders throughout the organization to promote and provide quality and compliance education that helps Sinai Chicago meet its mission and vision
• Serves as the Department of Nursing point of contact for surveyors during regulatory visits
• Collaborates with multidisciplinary professionals to integrate evidence-based interventions into a comprehensive plan of care to enhance patient outcomes
• Evaluates effects of system interventions for individuals and populations of patients/clients for clinical effectiveness, patient responses, efficiency, cost effectiveness, customer satisfaction and ethical considerations
• Identifies interpersonal, technological, environmental or system facilitators and barriers to the system implementation process
• Works collaboratively with interdisciplinary team to implement innovative evidence-based interventions that improve patient outcomes
• Represents Sinai Chicago on various advisory boards and commissions
• Mentors nursing and clinical staff at all levels of the organization to acquire new skills and develop their careers
• Works independently within the scope of nursing practice. The Executive Director for Nursing Professional Development will act as coach and mentor, provide direction, guidance, and feedback regarding practice and performance
• Performs other duties as assigned

Education and Work Experience:

• Bachelor of Science in Nursing (BSN) required
• Master's or higher-level degree in Nursing from an accredited school of Nursing preferred
• Five (5) years of clinical or leadership experience as a Registered Nurse
• Three (3) years of Nursing leadership experience
• Two (2) years of Nursing quality and/or regulatory compliance experience
• Knowledge of and experience working in Magnet recognized facilities
• Knowledge of NDNQI platform experience preferred

Knowledge and Skills:

• Intermediate computer skills with the ability to become proficient in Microsoft Office and electronic medical record systems with on-the-job training
• Strong data and systems analysis skills
• Ability to lead staff development initiatives to successful outcomes, and effectively utilize data, particularly with respect to evidence-based practices
• Excellent interpersonal skills with the ability to establish strong and effective collaborative relationships
• Excellent communication skills to prepare written materials and correspond with administrative personnel and the general public
• Excellent interpersonal skills and demeanor that promote effective interaction with multi- disciplinary health care providers, academic departments, vendors, and others
• Knowledge of research/evidence-based practice initiatives
• Experience in EPIC and MEDITECH software systems preferred.

Certifications/Licenses:

• RN licensed in the state of Illinois

Workplace Conditions:

PHYSICAL DEMANDS:

• While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle or feel; and talk or hear
• The employee frequently is required to walk and stoop, kneel, crouch
• The employee is occasionally required to stand
• The employee must occasionally lift and/or move up to 25 pounds.
• Specific vision abilities required by this job include close vision, distance vision, and ability to adjust focus

WORK ENVIRONMENT:

• General office environment and the noise level in the work environment is usually moderate

BLOOD-BORNE PATHOGEN EXPOSURE CATEGORY:

Category 1 - Job usually involves contact with patients or patient's specimens. Exposure to blood, body fluids, non-intact skin or tissue specimens, is possible

Category 2 - Job may expose incumbent occasionally or in emergency situations to blood, body fluids, non-intact skin or tissue specimens

Category 3x- Job does not involve exposure to blood, body fluids, non-intact skin or tissue specimens. Incumbent does not perform or help in emergency medical care or first aid as a part of his/her job.

Benefits:

Sinai Health System's goal is to provide you with the most comprehensive benefit package possible while balancing our fiscal commitments and obligations. Sinai Health Systems currently offers its employees the option to participate in a full range of benefits, including a health care program which includes medical, dental, vision and prescription coverage. Along with Employer Paid Life and Accidental Death & Dismemberment (AD&D), Supplemental Life, Short-Term and Long-Term Disability, Health Savings Account (HSA) and Flexible Spending Account (FSA), Employee Assistance Program and Student Loan Assistance. Participation in some programs requires that employees be regularly scheduled to work a minimum number of hours and/or to have fulfilled a waiting period after they begin employment with Sinai Health Systems.

Registry (per diem) Caregivers are caregivers who work less than 1,000 hours in a calendar year. Registry caregivers are employees of Sinai Health System but are typically on an as needed basis. These caregivers may be called upon to cover full-time or part-time caregivers during PTO events or sick leave as well as to provide supplemental coverage. Registry Caregivers are not eligible for Sinai's benefit programs with the exception for Sick-C, PPO Medical Plan, Employee Assistance Program (EAP) and non-match eligible contribution to the Sinai Health System Consolidated 403(b) retirement savings plan.

Living the Values:

• TEAMWORK - Caregiver works together with other caregivers to create and maintain an inclusive workplace where differences, inclusivity, conflict resolution and open communication are valued
• RESPECT - Caregiver shows mutual respect and fairness, treats each person with dignity and encourages each individual's unique talents and contributions
• QUALITY - Caregiver improves our services by following protocol and suggesting improvements based on observations, continuous learning and industry best practices
• INTEGRITY - Caregiver holds self and others accountable for their actions and are honest and ethical in all dealings
• SAFETY - Caregiver practices behaviors that promote safety for all patients, visitors, and caregivers
• ROLE MODEL - Caregiver is a dependable role model and champions our values through their daily interactions with patients, customers and coworkers