E&O Compliance Specialist

Occupational Summary:

Assist with planning, analyses, and implementation of strategies to ensure safety and regulatory compliance for construction, renovation and maintenance programs for Duke Health facilities served by Engineering and Operations (includes Duke University Hospital, clinics, School of Medicine, Ambulatory Services, and Duke Regional Hospital). Contribute to the achievement of the organization's mission through the development and leadership of performance improvement activities in the operational and/or clinical areas. Assist with assuring continual compliance with regulations and accreditation standards through monitoring activities and the design and implementation of strategies to enhance compliance. 

Work Performed 

• Support organizations efforts to maintain compliance with regulations and accreditation standards. 
• Monitor compliance through formal and informal processes. 
• Recognize opportunities for improving compliance. 
• Design and implement strategies for enhancing compliance. 
• Serve as an expert resource on performance improvement and compliance as it relates to organizational role. 
• Assist in planning activities aimed at improving the organization’s performance in operations and clinical quality. 
• Assist in the development of business plans, including market analysis, SWOT analyses, and financial pro formats. 
• Identify opportunities for improved performance. 
• Analyze data to identify adverse trends and/or undesirable performance. Utilize performance improvement techniques and methodologies. 
• Establish performance targets. 
• Design and implement strategies for enhancing performance. 
• Evaluate effectiveness of improvement strategy through sustained monitoring of performance. 
• Contribute to the establishment of performance improvement priorities for departments, functional units and for the organization. 
• Evaluate effectiveness of improvement strategy through sustained monitoring of performance. 
• Increase organizational understanding of performance improvement methodologies and principles and compliance through the support of and participation in formal and informal professional development activities. 
• Produce reports and presentations on performance improvement and compliance. 
• Develop, maintain and enhance knowledge through orientation, self-evaluation and professional development. 
• Responsibilities may include varying levels of strategic planning and human and fiscal resource management. 

Perform other related duties incidental to the work described herein. 

The above statements describe the general nature and level of work being performed by individuals assigned to this classification. This is not intended to be an exhaustive list of all responsibilities and duties required of personnel so classified. 

Required Qualifications at this Level 

Education/Training 

Work requires communicative, cognitive, and analytical skills normally acquired through a bachelor’s degree. 

Experience 

Work requires a minimum of three years of related business/administration experience. 

OR AN EQUIVALENT COMBINATION OF RELEVANT EDUCATION AND/OR EXPERIENCE 

Work performed (supporting DUH, Clinics, SOM, Ambulatory, DRH): 

• TJC Reporting and Compliance 

• Serve as a Joint Commission subject matter expert for E&O-specific Environment of Care compliance matters. 

• Develop new strategies to provide better oversight to meet regulatory requirements. 

• Conduct facilities related EOC Rounds to record discrepancies and follow to completion. 

• Collaborate on any Corrective Action Plans for affected E&O areas. 

• Conduct reviews of necessary reports for accuracy and intention to meet regulatory or accreditation standards. 

• Fire Safety & Fire Marshal 

• Serve as the E&O contact for ~120 annual Fire Marshall visits for E&O-controlled spaces. Review and respond to site visits following fire marshal or OESO-Fire Safety feedback. 

• Collaborate with OESO-Fire Safety on user requests to modify space use and proactively provide guidance on allowable changes and/or required physical modifications necessary to be code compliant. 

• Key Control 

• Conduct regular Key Control Audits for E&O-controlled space to ensure safety and accountability. 

• HEOWG (Healthcare Environment Oversight Work Group) 

• Serve as a subject matter expert for HEOWG with duties to include: 

• Validation and auditing of the Duke Health Water Management Plans. 

• Continual development of Duke Health’s Water Management Plans to address compliance with TJC accreditation standards, including up-to-date knowledge on control measures, facility risk assessments and collaboration with other key stakeholders. 

• Continual development and implementation oversight of an enhanced Air Pressure, Temperature, and Relative Humidity monitoring policy, including documentation, data review, and recordkeeping.

Minimum Qualifications

Education

Work requires a Bachelor's degree

Experience

Work requires a minimum of five years of related business/administration OR AN EQUIVALENT COMBINATION OF RELEVANT EDUCATION AND/OR EXPERIENCE experience.

Duke is an Affirmative Action/Equal Opportunity Employer committed to providing employment opportunity without regard to an individual's age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, sex, sexual orientation, or veteran status.

Duke aspires to create a community built on collaboration, innovation, creativity, and belonging. Our collective success depends on the robust exchange of ideas—an exchange that is best when the rich diversity of our perspectives, backgrounds, and experiences flourishes. To achieve this exchange, it is essential that all members of the community feel secure and welcome, that the contributions of all individuals are respected, and that all voices are heard. All members of our community have a responsibility to uphold these values.

Essential Physical Job Functions: Certain jobs at Duke University and Duke University Health System may include essentialjob functions that require specific physical and/or mental abilities. Additional information and provision for requests for reasonable accommodation will be provided by each hiring department.