| 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