Patient Safety Coordinator

Regulatory Compliance Specialist

Ensures organizational compliance with quality measures and performance indicators as required by regulatory and accrediting entities. Contributes to the development of goals, objectives, and performance standards while ensuring adherence to policies and regulations. Coordinates and educates on patient safety and regulatory compliance activities and motivates staff. Supports management of the event reporting system and the hospital's Performance Improvement Program by collaborating on risk reduction strategies. Applies tools and methodologies related to patient safety, outcomes measurement, process improvement, and root cause analysis, and works to support a systematic, organization-wide approach to monitoring and improving performance. Participates in policy development and revision, ensures compliance with organizational standards, and maintains collaborative relationships with key medical staff and stakeholders.

Primary Responsibilities

Leads and supports hospital-wide regulatory readiness activities to ensure compliance with Joint Commission, CMS, DMHS and Maryland state requirements.

Prepares for and participates in accreditation surveys, including coordination of survey logistics and response to surveyor requests.

Supports survey command center operations by tracking and fulfilling documentation requests (e.g., policies, logs, personnel files, contracts).

Conducts tracers and internal regulatory assessments; documents findings and supports staff education and compliance improvement.

Collects, abstracts, validates, and analyzes data from the EHR and other sources to monitor compliance with regulatory and quality standards.

Monitors action plans resulting from audits, surveys, and internal reviews, including concurrent and retrospective chart audits.

Collaborates with providers and departments to improve clinical documentation and meet regulatory requirements.

Participates in EHR (Epic) optimization efforts to ensure required documentation elements align with regulatory standards.

Ensures data integrity and may serve as a steward for external reporting to regulatory and accrediting bodies.

Provides ongoing education, feedback, and guidance to staff on regulatory changes, quality measures, and performance improvement initiatives.

Coordinates patient safety programs, including event review processes (RCA, ACA), investigations, and corrective action planning.

Manages the event reporting system, including daily review, trend analysis, and proactive identification of risk reduction opportunities.

Partners with leadership to promote a culture of safety and advance high reliability principles.

Develops and delivers patient safety education and serves as a consultant to departments on quality, safety indicators, and process improvement.

Supports patient safety governance by participating in committees, regulatory reporting, proactive risk assessments, and policy development to ensure ongoing compliance.

Perform all other duties as assigned.

Work Experience

Education & Experience - Required

Current licensure as a Registered Nurse (RN), Physical Therapist (PT), or Occupational Therapist (OT).

Three (3) years of previous clinical experience.

One (1) year of progressively responsible professional experience performing quality and/or regulatory compliance review or equivalent.

Education & Experience - Preferred

Additional education beyond the minimum required for licensure (e.g., BSN, DPT, OTD, or related advanced degree)

Previous experience collecting, analyzing, and submitting quality or regulatory data

Knowledge, Skills, & Abilities

Demonstrated expertise in data management, including data collection, validation, analysis, and report development.

Proficiency in navigating computer applications and electronic health records (EHRs) to abstract and analyze required data.

Ability to effectively utilize external databases for retrieving, analyzing, and submitting publicly reported quality data.

Working knowledge of data abstraction methodologies and core measure definitions preferred.

Strong oral and written communication skills, with the ability to effectively engage clinical staff, leadership, administrators, and external stakeholders.

Ability to work independently with minimal supervision, manage multiple projects, and demonstrate initiative and problem-solving skills.

Demonstrated ability to collaborate across disciplines, build effective relationships, and contribute to team performance and process improvement initiatives.

Self-motivated with strong critical thinking and analytical skills.

Proficiency in Microsoft Office Suite, including Word, Excel, and PowerPoint.