Quality Accreditation Coordinator - Pediatric Oncology
Review of all Continual Survey Readiness (CSR) efforts for the department of Hematology/Oncology and BMT. Promote a standard and effective approach to ensure the oncology department is continually ready for an accreditation survey. Creating a culture of CSR at all levels and locations of NCH.Update standard operating procedures/policies yearly or as required by the accreditation bodies of Hematology/Oncology/ BMT accreditation standards (COC, FACT, COG and ACOS).
- Review and maintains quality measures for FACT, ACOS, and COG as needed.
- Maintains master plan as required by accreditation bodies, prepare agenda for meetings, and monitor meeting attendance to ensure compliance with all Hematology/Oncology/BMT accreditation standards.
- Coordinate activities related to quality management plan in clinical, apheresis, and processing facilities of Bone Marrow Transplant (BMT).
- Communication with contracted vendors to monitor compliance of quality measures related to Bone Marrow Transplant (BMT). Audit and Compliance
- Perform or delegate audits, collect data in clinical, collection and processing facilities, and present it to the BMT program director.
- Assist the apheresis coordinator in developing policies and developing a system for audits and validations as required by FACT accreditation agency.
- Analyzes quality data collected in Hematology/Oncology and BMT related to readiness and as primary resource, reviews, monitors, and analyzes data.
- Promote a standard and effective approach to ensure Hematology/Oncology and BMT Unit is continually ready for an accreditation survey.
- Assist the Medical Directors, BMT Coordinator, Cancer Registry, and COG department with accreditation preparation survey. Assume role of liaison in the absence of Accreditation Administrator.
- Serve as a liaison with NCH departments, bone marrow, and stem cell processing facility in areas of reporting, quality, and accreditation results/feedback.
- Participates in multi-disciplinary rounds to provide problem solving and expertise in HMOG.
- Attend ancillary departmental meetings (Tumor Board, BMT, Blue Team, etc.) as required. Common Duties:
- Professional accountability to ensure compliance thru timely completion of licensures, certifications, competencies, health requirements (PPD, Flu), initial competencies & education requirements
- Maintains accountability by meeting the Service Excellence Index standards and complying with the attendance guidelines/procedures and ensures behavior is compliant with communication standards. Knowledge/Skills/Abilities:
- Experience in quality/performance improvement preferred.
- Career Development: National certification Pediatric Nurse (CPHON) OR (BMTCN) within 5 years of hire preferred.
- Ability to establish a positive working relationship and rapport with medical staff, other department heads, staff, and colleagues.
- Ability to prioritize, work independently, and evaluate workload in order to meet deadlines.
- Continuously improving professional growth and expertise through participation in relevant conferences, training, and educational activities.
- Ability to create reports using Microsoft Office.
- Ability to navigate the EMR.
- Ability to conduct quality review and develop action plans.
- Ability to maintain documentation for regulatory compliance.
- Excellent written and oral skills.
- Reacts effectively to unplanned circumstances, demands, and challenges facing the hospital and in the particular assigned area (HEMOC) of responsibility.
- RN licensure within the State of Florida in good standing prior to expiration and throughout employment.
- Minimum 2 years of clinical RN experience.
- Prior experience in quality assurance.
- CPR: Healthcare Provider in good standing prior to expiration and throughout employment.
- PALS within one year of hire in good standing prior to expiration and throughout employment
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