General Description:

Under general direction, works within the Department of Patient Safety & Regulatory Accreditation to independently facilitate and oversee projects at OU Health facilities. Responsible for managing the Patient Safety Evaluation System (PSES), analyzing safety events, and supporting risk mitigation efforts. Environment of Care (EOC) compliance projects and survey readiness projects as assigned by the leadership team.

Essential Responsibilities:

Responsibilities listed in this section are core to the position. Inability to perform these responsibilities with or without an accommodation may result in disqualification from the position.

• Monitor and investigate safety reports involving patients, staff, and visitors.

• Identify critical events and escalate to Clinical Risk Program Manager.

• Track and trend data on near misses, adverse events, and incidents.

• Provide education and resources on patient safety and risk management.

• Collaborate with departments to promote safe practices.

• Administer CMS rounding and Compliance Connect software systems.

• Monitor regulatory changes and implement committee recommendations.

• Oversees Performance Improvement Process related to Environment of Care compliance.

• Develops and distributes Environment of Care compliance tools to managers, directors, and staff for continuous survey readiness.

• Coordinates multidisciplinary Environment of Care rounds.

• Build weekly dashboards for the rounds in “CMS rounding” software.

• Ensure that each finding has documented follow up and completion by the involved unit directors.

• Conduct compliance audits to ensure sustainability with the action plans.

• Serves as a liaison between OUH and regulatory agencies during on-site survey activity.

• Oversees logistics for recruiting and training guides/scribes, scheduling conference rooms, and ensuring surveyors are scheduled to speak with OUH staff.

• Serve as Administrator for Facilities Survey Inc “CMS Rounding” software.

• Build and maintain audit question sets and tie to regulatory standard.

• Collaborates with Life Safety leadership to ensure the software build meets all needs.

• Monitors upcoming and released new standards, regulations, and CMS Conditions of Participation.

• Collaborates with appropriate staff to implement EOC Committee recommendations.

• Assists the department with education initiatives, including Regulatory Bootcamp, as required by applicable regulations.

• Drafts regulatory documents such as corrective action plans, newsletters, and other educational resources.

• Serves as Administrator for OUH Regulatory Auditing system utilizing software system.

• Updates leadership mapping and escalates Regulatory issues to the administrative team as appropriate.

• Assists in scheduling events via Microsoft Outlook.

General Responsibilities:

• Performs other duties as assigned.

Minimum Qualifications:

Education:  Bachelor's Degree required.

Experience: Three (3) years of relevant administrative experience required.

License(s)/Certification(s)/Registrations(s): None.

Knowledge, Skills, and Abilities:

• Advanced organizational and planning skills.

• Advanced verbal and written communications skills.

• Proficiency in Excel, Word, PowerPoint, PowerBI, and Salesforce.

• Ability to maintain effective working relationships during stressful conditions.

• Ability to maintain confidentiality of information.

• Ability to work independently and demonstrate good decision-making skills.

• Advanced critical thinking skills.