Regulatory/Accreditation Consultant
Full Time, 1.00 FTE, Day position.
About the role
Supports coordination and facilitation of accreditation and regulatory work for hospitals within assigned networks. Accountable for accreditation regulatory program with assigned scope of responsibility to include, but not limited to identifying gaps in compliance with state hospital licensing and accreditation standards, communicating to leadership on high-risk compliance issues, and supporting the development of local leaders and staff to be aware of rules pertaining to their areas of responsibility relating to regulatory compliance. Works with other disciplines and regulatory departments to coordinate compliance efforts across the PeaceHealth system. Serves the organization to promote operational standardization by maintaining one interpretation throughout PeaceHealth as it applies to rules and regulations monitored by this department.
Responsibilities
- Leads regulatory survey readiness program planning to support PeaceHealth’s mission, vision and values as related to regulatory compliance.
- Works with regulatory team, local leadership, stakeholders, and subject matter experts to provide oversight to ongoing regulatory readiness within the networks.
- Conducts tracers, internal audits and rounding activities to identify vulnerabilities and to validate compliance with accreditation and regulatory standards.
- Communicates information and report(s) to appropriate managers, committee, and leadership.
- Proactively addresses accreditation and regulatory compliance issues; works with other departments/system staff to assign ownership and works to correct identified issues prior to external regulatory review.
- Supports post survey activities, which include creation and continued monitoring of corrective action plan activity.
- Maintains required reports and summaries of noncompliant issues and survey activity in appropriate databases and updates as needed.
- Utilizes information to prioritize and provide regulatory reports to facilities as scheduled.
- Provides on-site accreditation survey support.
- Works with system and local regulatory team to assure the Survey Command Center is always ready to support survey processes.
- Serves a key support in the Command Center during survey.
- Assists in education and training of local leaders regarding command center functions.
- Documents and processes with facility management and leaders.
- Reviews survey materials at least quarterly and education at least biannually to ensure strong coordination and staff knowledge of role during external surveys.
- Assists with the development and implementation of regulatory education and core educational materials for leaders and caregivers.
- Provides local regulatory expertise to promote operational compliance using standard tools and approaches, consistent interpretation of rules and regulations, standardization of process/practice, and outcomes management.
- Participates and assists with the creation of standard work processes pertaining to department; educates and orients local leaders to standard work processes.
- Participates on system and/or local teams charged with regulatory improvement work as needed.
- Serves as the liaison between assigned accreditation/regulatory bodies and the hospital.
- Creates tools for managers to utilize to maintain compliance in their designated units.
- Provides expertise and leadership in the development and implementation of action plans including measurement support.
- Serves as coach or trainer to make sure assigned caregivers know responsibilities and expectations.
- Ensures executive support and process owners’ engagement in post-survey needs.
- Directs on-site accreditation survey support.
- Facilitates review and training of survey command center functions, documents and processes with facility management and leaders.
- Serves as a consultative resource and is available by phone/email for accreditation/CoP questions, research on state regulations, consult on approaches to compliance, etc.
- Performs other duties as assigned.
Qualifications
Education: Associate Degree Required: RN or other clinical background and Bachelor's Degree Required: in health-related field or equivalent knowledge and skills obtained through a combination of education, training and experiences.
Experience: Minimum of 5 years Required: Experience in healthcare discipline, regulatory, patient care, quality or risk and Preferred: Knowledge of state, federal and accreditation requirements including but not limited to: CMS Conditions of Participation for acute care and critical access hospitals, Accreditation standards and other regulatory areas such as FDA and OSHA.
Credentials Preferred: Registered Nurse.
Skills
- Excellent verbal and written communication skills. (Required)
- Excellent organizational skills. (Required)
- Excellent interpersonal skills. (Required)
- Ability to make independent judgment and pay close attention to details. (Required)
- Ability to maintain confidentiality of highly sensitive information. (Required)
- Ability to prioritize and manage multiple projects. (Required)
- Proven skills in team facilitation, project implementation, effective data interpretation, customer relations. (Required)