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Form of work
SalaryJob Title:
Regulatory and Accreditation Compliance SpecialistReq:
2023-0912Location:
HospitalDepartment:
Quality InitiativesSchedule:
Job Description:
- Serves as a professional resource and organizational leader for Joint Commission Accreditation/ Certifications, Pennsylvania Department of Health licensure regulations and Center for Medicare and Medicaid conditions of participation to maintain a state of continuous readiness and quality patient care.
- Maintains a solid working knowledge of regulatory body standards, including Joint Commission, CMS and PA DOH.
- Provides leadership in implementation of action planning to assure compliance. This includes but is not limited to plans of correction following onsite reviews, accreditation and certification surveys as well as citations requiring action plan development and execution.
- Provides regulatory consultation for the organization to ensure alignment with regulations, including but not limited to the coordination and execution of clinical and non- clinical tracer activities throughout the organization and performance of risk assessments.
- Collaborates with all hospital departments to assist in developing and maintaining strategies to successfully comply with the regulatory environment.
Acts as hospital liaison to regulatory agencies for survey applications, coordination of site/ survey activities and communications as required by those agencies
Monitors pertinent references and resources to identify changes to accreditation standards, regulations and conditions of participation. Prepares the organization to comply with these standards, regulations and conditions of participation.
Participates in the Joint Commission application process, develops and/ or monitors action plans.
Coordinates plans of correction and evidence of standards compliance through documentation and collaboration with organizational associates.
Orchestrate and participate in survey and licensure processes as appropriate.
- Collaborates and guides multidisciplinary teams through disciplined improvement approach to achieve desired results.
- Partners with organizational leaders regarding identification of process and outcomes measures, establishment of data collection tools and strategies, collection of baseline data and providing analyses to establish areas of improvement focus.
- Utilizes rapid cycle improvement methodology to encourage project momentum and evaluate improvement strategies.
- Provides guidance for improvement teams and departmental QAPI projects through coaching in all phases of project management for the achievement of their goals.
- Applies FMEA methodology for high risk processes with demonstrated avoidance of failures and harm within those processes as appropriate.
- Strategically develops, evaluates, and executes the organizational quality, patient safety and performance improvement program in partnership with the Director of Quality Initiatives
- Reviews and evaluates information from outside safety and quality organizations for improvement and growth opportunities within Doylestown Hospital's provision of clinical care.
- Elicits and encourages reporting of safety events, both those that reach the patient and those with the potential to negatively impact patient care.
- Develops safety and improvement messaging for associates as an ongoing strategy.
Job Qualifications:
- Education
- Bachelor's degree in a health care related field is required, Master's degree preferred
- CPHQ preferred
Licensure: RN preferred
Experience: Minimum of three years in accreditation / regulatory environment
Other Skills:
Knowledge and experience with licensing regulations and Accreditation standards
Initiative, judgment, creativity and leadership abilities
Experience in use of Model for Improvement, Lean Six Sigma, PDSA
Competence in application of tools such as FMEA
Data management and analytics, expertise in development of process and outcome metrics
Facilitation of multi-disciplinary teams, strong interpersonal skills
Proficient in oral and written communication
Strong analytical and organizational skills
Proficient in Microsoft Office
