Job Description

　　The Lemuel Shattuck Hospital (LSH) is seeking a Regulatory Readiness Coordinator - RN V. Under the direction of the Chief Quality Officer for the hospital, the Regulatory Readiness Coordinator leads efforts to ensure continual organizational compliance and ongoing readiness with quality and patient safety standards and regulations required by The Joint Commission, Center for Medicare, and Medicaid Services (CMS), Department of Public Health (DPH) and other regulatory agencies as appropriate. The incumbent will develop, implement, and oversee regulatory readiness education, tracer, and standards assessment. You will actively support and participate in improvement activities designed to improve the quality and safe care of our patients.

　　Schedule: Monday - Friday 8:00AM-4:30PM

　　Duties and Responsibilities (these duties are a general summary and not all inclusive):

　　Responsible for the development, coordination, and implementation of the continual readiness plan for Joint Commission Accreditation and CMS Condition of Participation.Serves as the organizational expert for regulations surveyed through the Joint Commission accreditation standards, CMS condition of participation for hospitals. Supports and monitors compliance of policies and procedures with standards and regulatory requirements.Responsible for the interpretation and communication of the regulatory requirements and standards including the applicable hospital licensure requirements. This may include requirements from non-clinical agencies such as Occupational Safety and Health Administration (OSHA).Serves as the organizational contact for the Joint Commission account representative and maintains effective working relationship.Provides direction and guidance during the Triennial Joint Commission survey as the survey Command Center Leader.Oversees the development of remedial action plans and evidence of standards compliance for internal findings as well as any Joint Commission survey findings. Ensures the findings are reported to appropriate committees.Chairs the hospital Regulatory Readiness Committee and ensures committee charter, membership and functional responsibilities are supporting the ongoing readiness activities such as standards self-assessment, periodic performance review, tracer activities and action plans for any areas of non-compliance.Provides oversight and reports on the progress for ongoing assessment of the continual readiness plan, identification of needed improvements, and preparation and implementation of plans to achieve needed improvements. Ensures the effective use of regulatory readiness software to monitor progress.Develops and/or facilitates the development of tools, procedures and learning tools pertaining to regulatory readiness. Provides education and training for accreditation requirements in collaboration with Education Leader (RNVI).Leads or participates in hospital performance improvement including root cause analysis, causal analysis, proactive risk assessments including Failure Mode Effects analysis, regulatory readiness activities, and performance improvement methodologies including LEAN/Six Sigma.

　　Required Qualifications:

　　Knowledge of the principles and practices of healthcare.Comprehends the terminology and standard abbreviations in healthcare.Experience in the methods used in the preparation of charts, graphs, and tables.Knowledge of standard clinical policies, procedures, methods, and techniques.Experience in interviewing techniques.Knowledge of problem-solving techniques.Ability to understand, explain and apply the laws, rules and regulations governing agency operations.Can give written and oral instructions in a precise, and understandable manner.Ability to write clearly and concisely.Ability to gather information through observing and questioning individuals, and by examining records and documents.Can establish and maintain harmonious working relationships with others.Ability to participate in multi-disciplinary health care team.Ability to maintain confidentiality of patient information.Skill to analyze and determine the applicability of medical data, to draw conclusions and make appropriate recommendations.Knowledge of training methods and techniques.Ability to plan and conduct training or instruction in nursing.

　　Preferred Qualifications:

　　Knowledge of the laws, rules, regulations, policies, procedures, specifications, standards, and guidelines governing agency and assigned unit activities.Ability to explain the laws, rules, regulations, policies, procedures, specifications, standards, and guidelines.Knowledge of the methods used to evaluate nursing practices.Knowledge of the principles and practices of healthcare administration.Familiar of state laws, procedures, and guidelines.

　　About the Lemuel Shattuck Hospital:

　　Lemuel Shattuck Hospital is a fully Joint Commission accredited teaching facility that provides acute, subacute, and ambulatory care to patients referred by public agencies and private sector providers. Shattuck Hospital's services help economically and socially disadvantaged patients to get high quality, cost-effective care from a staff that respects their dignity.

　　Located in the heart of Boston's Jamaica Plain neighborhood, the Shattuck Hospital includes 248 inpatient beds including 95 Psychiatric beds and 29 Correctional Health beds. In addition, the Shattuck has a full outpatient clinic with many specialties that offers treatment to patients of the Department of Mental Health as well as Department of Correction and House of Correction inmates and community patients.

　　The Shattuck hospital is on the forefront of substance use disorder treatment including a Suboxone clinic serving 200 patients. In addition to direct medical services LSH hosts and supports an array of services located on the campus, serving patients struggling with addictions and homelessness.

　　Learn more about: what it's like to work as a DPH nurse

　　Learn more about Shattuck Hospital: https://www.mass.gov/locations/lemuel-shattuck-hospital

　　Relocation information: https://www.mass.gov/service-details/dph-renovation-for-shattuck-hospital-replacement-building

　　Pre-Hire Process:

　　A criminal background check will be completed on the recommended candidate as required by the regulations set forth by the Executive Office of Health and Human Services prior to the candidate being hired. For more information, please visit http://www.mass.gov/hhs/cori

　　Education, licensure, and certifications will be verified in accordance with the Human Resources Division's Hiring Guidelines.

　　Education and license/certification information provided by the selected candidate(s) is subject to the Massachusetts Public Records Law and may be published on the Commonwealth's website, http://www.mass.gov

　　If you require assistance with the application/interview process and would like to request an ADA accommodation, please click on the link and complete the Reasonable Accommodation Online Request Form

　　For questions regarding this requisition, please contact Executive Office of Health and Human Services, Human Resources at 1-800- 510-4122 Ext. #2

　　Qualifications

　　 First consideration will be given to those applicants that apply within the first 14 days.

　　MINIMUM ENTRANCE REQUIREMENTS:

　　Applicants must have at least (A) three years of full-time, or equivalent part-time, experience as a registered nurse in a recognized hospital, clinic or medical facility and (B) of which at least two years must have been in a supervisory, administrative, or managerial capacity, or (C) any equivalent combination of the required experience and the substitutions below.

　　Substitutions:

　　I. A Graduate degree with a major in Nursing may be substituted for a maximum of one year of the required (A) experience. No substitutions will be allowed for the required (B) experience.

　　Education toward such a degree will be prorated on the basis of the proportion of the requirements actually completed.

　　SPECIAL REQUIREMENTS FOR ALL LEVELS IN SERIES: Current and valid registration as a professional nurse under the Massachusetts Board of Registration in Nursing .

　　Recent graduates from an approved school of nursing must have applied for the first available registered nurse examination.

　　Special Requirements: Based on assignment, possession of a current and valid Massachusetts Motor Vehicle Operator's license may be required.

　　Comprehensive Benefits

　　When you embark on a career with the Commonwealth, you are offered an outstanding suite of employee benefits that add to the overall value of your compensation package. We take pride in providing a work experience that supports you, your loved ones, and your future.

　　Want the specifics? Explore our Employee Benefits and Rewards!

　　COVID Vaccine: As a condition of employment, depending on job assignment and location, employees may be required to have received COVID-19 vaccination and/or other vaccinations, or to have been approved for a vaccination exemption prior to their start date. Details relating to demonstrating compliance with this requirement will be provided to applicants selected for employment.

　　An Equal Opportunity / Affirmative Action Employer. Females, minorities, veterans, and persons with disabilities are strongly encouraged to apply.

　　The Commonwealth is an Equal Opportunity Employer and does not discriminate on the basis of race, religion, color, sex, gender identity or expression, sexual orientation, age, disability, national origin, veteran status, or any other basis covered by appropriate law. Research suggests that qualified women, Black, Indigenous, and Persons of Color (BIPOC) may self-select out of opportunities if they don't meet 100% of the job requirements. We encourage individuals who believe they have the skills necessary to thrive to apply for this role.