Coordinates quality, accreditation, regulatory and licensing (AR&L), patient safety and risk management activities for the medical center. Provides clinical, educational, consulting, and coordinating support to assigned areas. Uses nurses licensure as a substantial amount of scientific knowledge or technical skill for indirect patient care services that ensure the safety, comfort, personal hygiene, and protection of patients; and the performance of disease prevention and restorative measures.

• Acts as a consultant for quality, AR&L, risk, patient safety, and infection prevention activities and programs.


• Assists with quality management studies through data collection, data input and report development.


• Analyzes, interprets and provides recommendation based on quality principles.


• Organize and coordinate project planning, group process facilitation, training, and appropriate application of information technology.


• Reports all occurrences which may lead to medical center liability and follows up as necessary.


• Facilitates interdisciplinary collaboration for implementation of evidence based guidelines, criteria and other clinical tools to reduce variation in clinical practice and to optimize clinical outcomes.


• Educates physicians and staff regarding regional projects or regulatory reviews, i.e. the interpretation of regulatory requirements and the methods of compliance when preparing for a review or the interpretation of project goals.


• Analyzes risk management/patient safety principles and provides recommendations for the incorporation of risk management principles in each medical center.


• Provides support services to appropriate medical center staff in implementing risk management principles into credentialing processes.


• Participates in special projects as assigned, such as statistical reports for state, federal, and local agencies.


• Applies the appropriate performance improvement methodology to address improvement opportunity (eg. MFI, Lean DMAIC).


• May support infection prevention and control activities.


• Supports maintenance of IC records and policy/procedure manual reviews and revisions.


• Supports the medical centers continuous survey readiness program to maintain compliance with regulatory standards.