Job Description

Works independently under the general to ensure compliance with accreditation and regulatory standards. Responsible for development, implementation, and evaluation of processes to support ongoing compliance with The Joint Commission, Maryland Department of Health, Centers for Medicare & Medicaid (CMS) and other regulatory bodies as required. Leads and works collaboratively with internal and external partners to achieve continuous regulatory and accreditation compliance, positive survey outcomes, and a safe environment for patients and staff.

Qualifications

Bachelors of Science in Nursing or equivalent Health Care Field (required)

Masters of Science in Nursing or equivalent Health Care Field (preferred)

Five (5) years’ of previous clinical experience in hospital including experience with facilitating and leading safety and quality improvement initiatives is required. Previous experience in quality or safety role preferred.

Current Maryland license in good standing as Registered Nurse (required)

CPHQ (preferred)

Additional Information

All your information will be kept confidential according to EEO guidelines.

1. Assumes primary responsibility for, organizes, coordinates and leads activities and improvements related to accreditation and regulatory compliance. Responsible for the development and coordination of action plans and the monitoring of action plans in order to sustain improvements.
2. Collaborates with all staff, clinical professionals and administrative leadership to foster a culture of accreditation readiness thereby assuring safety, quality care and regulatory compliance.
3. Harmonizes improvement efforts with other activities in the organization utilizing knowledge of accreditation standards. Participates in safety, environmental, and leadership rounding. Works with Leaders and Physicians to organize and incorporate accreditation readiness communication into standing meetings and huddles.
4. Leads clinical audits/assessments and chart reviews to identify accreditation and compliance issues. Utilizes data from a variety of sources to identify opportunities to improve the systems in the delivery of care. Validates electronic data as appropriate.
5. Leads, coordinates and facilitates RCAs and FMEAs in response to sentinel/adverse events.
6. Conducts tracers and identifies accreditation and regulatory compliance issues at unit, department, and organizational level, and provides timely and actionable feedback to physicians and staff. Collects, enters, aggregates, and trends tracer findings, and presents results to unit, departments, and leadership. Develops targets and improvement plans when necessary. Trains staff and leaders in tracer activities.
7. Participates in onsite visits by regulatory agencies including “for cause visits” and “complaint investigations”.
8. Serves as the representative for external interaction with accrediting and regulatory bodies. Primary point of contact for all agencies during announced and unannounced surveys. Chairs the Regulatory Readiness Committee, Regulatory Oversight Committee and Other Committees as assigned. Manages official communication with accrediting and regulatory bodies, assuring timely completion of all submissions, including (not limited to) applications, periodic reviews, corrective action plans, and responses to inquiries and survey findings.
9. Develops and leads innovative new programs to increase involvement of front-line staff and all care team members in accreditation related initiatives. Builds strong working relationships with all clinic staff and management to help achieve compliance.
10. Identifies needs for educational programs; develops and delivers multidisciplinary educational sessions, or facilitates and coordinates obtaining training sessions utilizing knowledge of patient safety risks, quality, regulatory standards and policies. Participates in the education of medical staff, employees, and leadership.
11. Serves as the expert regarding Joint Commission and CMS standards, and stays abreast of changing regulatory requirements. Maintains current knowledge of certification requirements as applicable to the organization.
12. Coordinates meetings, creates agendas, and determines membership for regulatory related meetings.
13. Gathers metrics where applicable.
14. Does related work as assigned