The Director of Nursing Quality and Regulatory Compliance reports to Associate Nurse Executive of Quality, Development, and Advanced Practice Nursing and is responsible for enhancing the clinical quality and outcomes of nursing practice through the use of clinical data and project planning, implementation and evaluation by applying evidenced-based best practices throughout Cook County Health (CCH). In addition, the Director of Nursing Quality and Regulatory Compliance is responsible for developing systems and processes, which ensure continual survey readiness and regulatory compliance. The CCH is made up of John H. Stroger Hospital, Provident Hospital, Oak Forest Health Center, the Ambulatory and Community Healthcare Network, the CORE Center, Cermak Health Services, and the Cook County Department of Public Health. The mission of the System is to provide high quality care to the residents of Cook County (IL) regardless of ability to pay.
This position is exempt from Career Service under the CCH Personnel Rules.
General Administrative Responsibilities
Review applicable Collective Bargaining Agreements and consult with Labor Relations to generate management proposals
Participate in collective bargaining negotiations, caucus discussions and working meetings
Document, recommend and effectuate discipline at all levels
Work closely with labor relations and/or labor counsel to effectuate and enforce applicable Collective Bargaining Agreements
Initiate, authorize and complete disciplinary action pursuant to CCH system rules, policies, procedures and provision of applicable collective bargaining agreements
Direct and effectuate CCH management policies and practices
Access and proficiently navigate CCH records system to obtain and review information necessary to execute provisions of applicable collective bargaining agreements
Contribute to the management of CCH staff and CCH’ systemic development and success
Discuss and develop CCH system policy and procedure
General Administrative Responsibilities
Consistently use independent judgment to identify operational staffing issues and needs and perform the following functions as necessary; hire, transfer, suspend, layoff, recall, promote, discharge, assign, direct or discipline employees pursuant to applicable Collective Bargaining Agreements
Work with Labor Relations to discern past practice when necessary
The Director of Nursing Quality and Regulatory Compliance assesses, plans, organizes, directs and evaluates overall nursing quality and regulatory compliance initiatives at the unit, divisional, departmental and system level. The Director collaborates with Nursing leadership, Nursing staff and other patient care related services, as well as those in Quality/Performance Improvement roles to enhance the quality of nursing practice through the use of clinical data and the application of evidence-based practice. Under the direction of the Associate Nurse Executive, Quality, Development, and Advanced Practice Nursing, specifically have responsibility for:
Providing leadership and direction in overall nursing quality and regulatory compliance.
Planning, coordinating, implementing and evaluating programs provided by CCH relative to quality improvement and regulatory compliance.
Utilizing various assessments and data, identify gaps in compliance from a quality and regulatory compliance perspective in the Department of Nursing.
Reporting at the system, divisional and departmental level survey readiness findings and action planning to ensure compliance.
Creating structure and processes to ensure optimal quality and compliant nursing performance.
Partnering with various service lines, departments and leaders throughout the organization to promote and provide quality and compliance education that helps CCH meet its mission and vision.
Serving as the Department of Nursing point of contact for surveyors during regulatory visits.
Representing the CCH on various advisory boards and Commissions.
Reports to the Associate Nurse Executive of Quality, Development and Advanced Practice Nursing
Licensed as a Registered Professional Nurse in the State of Illinois
Master's or higher level degree in Nursing from an accredited school of nursing
Five (5) years of clinical or leadership experience as a Registered Nurse
Three (3) years of nursing leadership experience
Two (2) years of nursing quality and/or regulatory compliance experience
Knowledge of and experience working in Magnet recognized facilities
Knowledge, Skills, Abilities and Other Characteristics
Knowledge of research/evidence based practice initiatives, and Microsoft Office.
Ability to: lead staff development initiatives to successful outcomes, and effectively utilize data, particularly with respect to evidence-based practices.
Excellent interpersonal skills with the ability to establish strong and effective collaborative relationships.
Excellent communication skills to prepare written materials and correspond with administrative personnel and the general public.
Physical and Environmental Demands
This position is functioning within a healthcare environment. The incumbent is responsible for adherence to all hospital and department specific safety requirements. This includes but is not limited to the following policies and procedures: complying with Personal Protective Equipment requirements, hand washing and sanitizing practices, complying with department specific engineering and work practice controls and any other work area safety precautions as specified by hospital wide policy and departmental procedures.
The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of the personnel so classified.
For purposes of the American with Disabilities Act, “Typical Duties” are essential job functions.
Cook County Health is an equal opportunity employer.
Internal Number: 8148
About Cook County Health
ABOUT COOK COUNTY HEALTH (CCH)
The Cook County Health’s mission is to deliver integrated health services with dignity and respect regardless of a patient’s ability to pay; foster partnerships with other health providers and communities to enhance the health of the public; and advocate for policies that promote the physical, mental and social wellbeing of the people of Cook County.
CCH is comprised of two hospitals, John H. Stroger, Jr. Hospital and Provident Hospital, a robust network of more than a dozen community health centers, the Ruth M. Rothstein CORE Center, the Community Triage Center, the Cook County Department of Public Health, Cermak Health Services, which provides health care to individuals at the Cook County Jail and the Juvenile Temporary Detention Center, and CountyCare, a Medicaid managed care health plan.
The system cares for more than 300,000 patients each year and its physicians are experts in their fields, committed to providing their patients with comprehensive, compassionate and cutting-edge care. Today, CCH is transforming the provision of health care in Cook County by promoting community-based primary and preventive care, growing an innovative, ...collaborative health plan and enhancing the patient experience.
COOK COUNTY HEALTH IS AN EQUAL OPPORTUNITY EMPLOYER