Regulatory Safety Officer 2

The Safety Regulatory Coordinator facilitates the development implementation and maintenance of the Hospital Emergency Preparedness Environment of Care and Safety Programs for St. Francis Medical Center and related entities. Leads processes for the development testing continuous improvement and management plans policies and procedures for all responsibilities. The position requires familiarity with a variety of the fields concepts practices and procedures and relies on extensive experience and judgment to plan and accomplish goals.

1. People: This will have been satisfactorily performed when
   1. A comprehensive team member communication and engagement plan as related to safety and regulatory compliance is developed and followed incorporating at minimum rounding on all shifts regular staff meetings staff involvement in planning and quality improvement activities recognition events performance and career coaching cascade learning from hospital leadership meetings and bulletin boards.
   2. St. Francis compliance for EOC Life Safety emergency preparedness relative to TJC CMS standards and Fire Marshal are assessed and met as determined by quarterly policy reviews with recommendations for improvements. Training for leadership and team members is provided as needed to assure compliance.
2. Service: This will have been satisfactorily performed when
   1. Standards of Performance for all required forms of rounding are consistently met.
   2. SFMC emergency preparedness policies are complete and current as assured through appropriate oversight.
   3. The EOC and internal emergency prepareness committees are managed as demonstrated as functioning as committee chair including all relevant committee agenda minutes and reports as evidenced by records.
3. Quality/Safety: This will have been satisfactorily performed when
   1. Regulatory agency surveys and mock surveys reveal miminal or no obvious deficiencies to their standards.
   2. Emergency Communication System is initiated through reliable communications systems (telephone computer faxes 700 MHz radios Ham Radios etc.) with connectivity to LHA at State EOC in the event of disaster to collect vital facility information.
   3. Emergency preparedness training is coordinated and implemented as demonstrated by successful emergency drills and safety surveillance.
   4. EOC meetings are conducted at least quarterly performs EOC/safety rounds monthly performs Fire drills once per shift per quarter.
4. Stewardship: This will have been satisfactorily performed when
   1. Annual goals objectives and action plans reflect and actualize FMOLHS and SFMC strategic and annual plans initiatives and challenges.
   2. Input is made into annual budget and budget performance and assistance is given to achieve SFMC staffing and supply utilization/inventory benchmarks/standards.
   3. All contributions of areas of responsibility are identified quantified and benchmarked with action plans to optimize developed approved implemented and made subject to regular PDCA review.
   4. Department operational policies and procedures for areas of responsibility are reviewed annually and updated as needed.
5. Growth: This will have been satisfactorily performed when
   1. Opportunities for SFMC to enhance community health wellbeing security wealth and/or productivity within the precepts and resources of its ministry are sought through a significant personal commitment of this incumbent to reaching out and engaging in health related community events service organizations etc. When practical opportunities are identified incumbent follows through with discussions proposals/business plans etc. to assure that opportunity is given due consideration.
   2. Formal notification and communication is held with for leadership related to EOC safety and all Joint Commission related information as changes occur and is documented as required.
6. Other Duties as Assigned: This will have been satisfactorily performed when
   1. Other duties as assigned are completed.

• Bachelors degree in related field or equivalent experience
• Good computer skills interpersonal & human relations skills and oral & written communication skills; good problem solving & critical thinking skills and time management/prioritization skills; good organizational skills