RN Program Coordinator - Regulatory Safety

Tacoma, WA
Contract Type
Full Time
CHI Franciscan Health has exciting and rewarding careers with competitive salaries and benefits.  We are a family of hospitals, health care services, and medical providers delivering compassionate care to people throughout the South Puget Sound. We are part of Catholic Health Initiatives, one of the largest not-for-profit health care systems in the country.

Our mission is to deliver high quality care that meets our patients' medical needs while providing emotional and spiritual support to patients and their families. We believe this three-part approach — physical, emotional, and spiritual — is essential to healing the whole person. Come join our team!

Job Summary:

This job is responsible for providing clinic support and coordination for the implementation of Patient Safety and Accreditation and Licensing programs.   An incumbent assures all facets of patient safety are identified, and coordinated into a comprehensive plan, and that Franciscan Medical Group (FMG) clinics are aligned with regulatory requirements and standards established through state and federal regulations.  An incumbent conducts ongoing regulatory compliance activities through extensive FMG clinic safety/regulatory rounding, assessing current standards/ identifying compliance gaps, reporting vulnerabilities to leadership and key stakeholders and preparing reports/plans of correction for remediation by management.  

Work also includes:  1) assisting in review/trending of FMG incident report information and providing quality information for presentations and for physician performance evaluation; 2) providing guidance and coaching to FMG management aimed at achieving continuous readiness and compliance with licensure, accreditation and with state and federal regulations; and 3) coordinating clinic compliance activities with external stakeholders.

Work requires knowledge of clinic-related regulations and safety requirements.  An incumbent is accountable for keeping knowledge and skills current in assigned subject area(s) through self-education, community networking and professional organization offerings.

Essential Duties:

  • Coordinates safety, regulatory, accreditation and licensing program activities for compliance with the Washington State Department of Health (DOH), Conditions of Participation (CoPs) and other state and federal standards, rules and regulations in FMG Clinics.  

  • Performs annual environment of care safety/regulatory inspections; documents findings and develops action plans based on variances identified; maintains records and follows up with leadership and/or clinic manager to ensure compliance with provisions of the action plan; monitors compliance and escalates non-compliance to management.

  • Participates in the Clinical Risk Management Incentive Plan (CRMIP); identifies projects and works proactively to ensure incentive plan requirements are met; maintains CRMIP records and documents. 

  • Coordinates/participates in performance improvement initiatives.  

  • Identifies regulatory compliance gaps and mentors leadership in developing plans to address and close the gaps to achieve outcomes, promote safe practices and achieve sustainable compliance with regulatory standards. 

  • Facilitates ongoing FMG clinic activities to ensure regulatory and safety requirements are met.

  • Coaches leaders in the implementation of action plans for ongoing process improvement to meet patient, employee and environmental health care and safety standards.

  • Leads the implementation of regulatory or safety-related policies and facilitates standardization across clinics where practical and necessary.  

  • Develops and recommends necessary improvement and corrective actions to FMG leadership/staff and follows implementation to completion.

  • Facilitates compliance with safety and regulatory requirements for FMG clinics; updates management on regulatory and safety initiatives and concerns.   

  • Maintains current knowledge of clinic risk, regulatory and safety requirements in accordance with established regulatory standards and guidelines (e.g. DOH, OSHA, HIPAA, etc).

  • Facilitates implementation of the bi-annual AHRQ Safety Culture Survey; tracks results and provides findings to management.

  • Coordinates and/or leads the FMG safety and safe patient handling committees; keeps management apprised of progress and barriers.

  • Collaborates with clinic educator(s) on required elements for safety training and disaster preparedness education; facilitates compliance with regulatory requirements.

  • Communicates requirements and collaborates with educator(s) to ensure education compliance with regulatory requirements related to point of care testing, sterilizer utilization, radiology requirements, etc.; consults with educator(s) on content delivery and tracking of education compliance.

  • Consults on new clinic acquisition and conducts a risk assessment; documents and communicates results to key internal stakeholders to facilitate regulatory and safety compliance.

  • Provides consultative services, coaches and facilitates key stakeholders and staff to help mitigate/resolve potential safety, health and environmental issues/deficiencies/violations (within defined scope of responsibility) in accordance with established clinic requirements and policy.

  • Serves as subject matter expert on regulatory issues, patient safety and accreditation; interprets and clarifies accreditation, CoP, DOH and other health care related safety standards.

  • Reviews and analyses complex patient safety events requiring knowledge of regulatory requirements.

  • Facilitates the implementation of survey readiness and regulatory education and communication plan for assigned hospitals and services.

  • Facilitates change in clinical practice based on findings from data collection, surveillance, studies and research; participates collaboratively in safety-related performance improvement activities/initiatives and in achieving quality/safety goals.

  • Works collaboratively with all levels of FMG Leadership/staff to manage processes designed to promote clinic-wide patient safety initiatives and to improve quality of care.

  • Provides education and regulatory updates to FMG Leadership, medical staff and management regarding changes in accreditation standards, COP or licensing regulations.

  • Works collaboratively with Risk Management, Infection Prevention/Employee Health, Informatics, Medical Staff and Education Services to facilitate communication and implementation of FMG quality improvement and safety plans.

  • Works collaboratively with Risk Management in facilitating analyses of problem processes or adverse events that have the potential to patient safety.

  • Works collaboratively with Quality Management personnel, medical staff and Infection Prevention on performance improvement initiatives or activities.

  • Collaborates with all levels of leadership and staff as needed to identify, review, follow-up and resolve patient safety and care concerns.

  • Performs related duties as required.

Additional Responsibilities: 

Adheres to and exhibits our Core Values of Reverence, Integrity, Compassion and Excellence.  


  • Bachelor’s degree in a healthcare related field and graduation from an accredited school of nursing and four years of progressively responsible experience in a clinic or acute care setting that demonstrates the attainment of the requisite job knowledge, skills and abilities.

  • Or, any equivalent combination of education and experience which meets licensure requirements and provides the required knowledge, skills and abilities to perform the essential functions of the position.


  • Current licensure as a Registered Nurse by the Washington State Nursing Commission.