Address
Form of workThe Accreditation and Regulatory Readiness Specialist supports NAH's mission to improve health and heal people by contributing to the Accreditation team's work to ensure that NAH meets or exceeds quality standards throughout the organization. This position will focus on management of the Document control system, but will also be asked to perform a wide variety of duties to support accreditation standards, Center for Medicare and Medicaid Services (CMS) conditions of participation compliance, and Arizona Department of Health Services (ADHS) regulations. Also may be asked to assist with center of excellence designations, certifications and other related-activities.
Document Control and Management
* Coordinate the Document Control team in the maintenance and management of the Document Control System.
* Implement workflows that ensure that information-related policies align with the most recent regulations.
* Track who owns and reviews documents and whether documents are up-to-date.
* Manage and update the system so that users can easily locate documents using common search terms.
* Develop education for system users, document owners, and those who approve documents.
* Collaborate with leaders across the organization to ensure that users receive appropriate training on use of the system.
Regulatory and Accreditation
* Assist with continuous survey readiness activities.
* Participate in the survey process.
* Support work related to ensuring that the organization understands and responds to survey findings.
Quality Review and Accountability & Health Data Analytics
* Promote compliance with voluntary, mandatory, and contractual reporting requirements for data acquisition, analysis, reporting, and improvement.
* Acquire data from source systems.
* Design data collection plans for key performance indicators.
* Select appropriate statistical tools and visualization methods to transform data into information.
Performance and Process Improvement
* Evaluate process improvement methods (e.g. LSS, PDSA) and apply those best suited to achieving successful outcomes.
* Access and use information resources (Regulatory standards, Electronic Health Records, registries, databases, comparative and benchmark data, and published research) to demonstrate current practice, identify opportunities for improvement, and strive toward improved outcomes.
* Use change management principles and tools.
Patient Safety
* Assess the organization's patient safety culture and work with leaders on identifying behaviors that impact safety culture.
* Apply safety science principles and methods to identify root causes and potential solutions when safety risks are discovered.
* Identify and report any safety related incident in a timely fashion through the Midas/RDE tool; attend all safety related training programs; perform work in a safe manner; monitor care environment for possible safety issues and ensure others are also performing work in a safe manner.
Professional Engagement
* Integrate ethical standards into healthcare quality practice.
* Engage in lifelong learning as a healthcare quality professional.
* Participate in activities that advance the healthcare quality profession.
Compliance/Safety
* Responsible for reporting any safety-related incident in a timely fashion through the Midas/RDE tool; attends all safety-related training programs; performs work in a safe manner; monitors work environment for possible safety issues and ensures others are also performing work in a safe manner.
* Stays current and complies with state and federal regulations/statutes and company policies that impact the employee's area of responsibility.
* If required for the position, ensures all certifications and/or licenses are up-to-date and valid prior to expiration dates.
* Completes all company mandatory modules and required job-specific training in the specified time frame.
Education
Bachelors Degree- Required
Three (3) years of healthcare experience - Required
Certification & Licensures
Process Improvement Experience and/or Training (LSS Green Belt or equivalent) - Preferred
Certified Professional in Healthcare Quality (CPHQ), Healthcare Accreditation Certified Professional (HACP), or Certified Joint Commission Professional (CJCP)- Preferred
Experience
Working knowledge of Microsoft Office - Required
Experience manipulating data and creating tables in Excel - Required
Experience supporting organizational accreditation (e.g. Joint Commission, DNV, CMS) - Preferred
Experience using Total Quality Management (TQM)/ Continuous Quality Improvement (CQI) - Preferred
Healthcare is a rapidly changing environment and technology is integrated into almost all aspects of patient care. Computers and other electronic devices are utilized across the organization and throughout each department. Colleagues must have an understanding of computers, and competence in using computers and basic software programs.
