Employees must abide by all Joint Commission Requirements including but not limited to sensitivity to cultural diversity, patient care, patient rights and ethical treatment, safety and security of physical environments, emergency management, teamwork, respect for others, participation in ongoing education and training, communication and adherence to safety and quality programs, sustaining compliance with National Patient Safety Goals, and licensure and health screenings.
* Oversees accreditation compliance of CMS and Joint Commission standards or regulation by state and local jurisdictions for the hospitals and buildings overseen by General Services.
* Collaborates with the Environmental Health and Safety team on multiple initiatives across Stanford Children’s. Shares data, outcomes, risk assessments and mitigation plans as needed.
* Facilitates the process for accreditation surveys, regulatory inspections, and insurance rounding. Presents documentation, leads survey groups, provides access to rooms and equipment requested by the surveyor.
* Writes and/or updates the Fire and Life Safety and Utilities Management Plans, risk assessments, and verifies code compliance for the building and equipment.
* Leads the Fire and Life Safety sub-committee, Utilities Management sub-committee, and Water Management committee. Participates in select regulatory meetings, such as the Environment of Care, Infection Prevention and Control, and Office of Emergency Management committees.
* Schedules, organizes documentation, and provides corrective action of compliance inspection, testing, and maintenance, including fire drills and Interim Life Safety Measures.
* Participates in the weekly Environment of Care Rounding with mulit-disciplinary team of managers and directors. Reports out findings, corrections, and any training that is needed.
* Uses data and completed risk assessments to provide recommendations to evaluate and improve the functions of the Fire and Life Safety and Utilities Management programs. Provides updates to the Environment of Care Committee as needed.
* Reviews construction drawing designs to validate Life Safety Code compliance. Completes Interim Life Safety Measures assessment to start construction work authorization. Maintains accurate and updated Life Safety Drawings.
* Manages the hospital’s water management program. Oversees and schedules vendors, reports findings, corrections, and conducts training that is needed.
* Collaborates with medical staff and other LPCH staff to ensure that the highest quality of service is being delivered to patients; continually strives to facilitate the productive efforts of all hospital staff members. Consistently assesses customer needs in order to develop and/or ensure that existing services maintain and deliver quality characteristics which meet the needs of customers and the external regulatory and statutory requirements.
* Educates staff / vendors / contractors on compliance for codes and policies. Assist to establish and deliver required training for Engineering staff for Cal-OSHA safety program.
* Manages multiple daily workflows for equipment rounding such as Elevator, Neg/Pos pressure rooms, and egress routes. Conducts ongoing process improvement initiatives to improve workflow and safety.