Accreditation Specialist - Full Time - Days

Job Description

Under the supervision of the Quality Program Manager, the Performance Improvement Specialist is responsible for implementation and monitoring of initiatives with a focus on improvement and compliance with the standards set by accreditation & regulatory agencies. To manage, within a collaborative environment, the execution of assigned components of strategic initiatives. To partner with stakeholders in development of project plans to ensure implementation of key business initiatives. To provide project management, facilitation, education, and data analysis support for the improvement of systems and processes. To assist in the coordination and aggregation of information for use by management in its decision making in both general operations and in tactical and strategic planning. This position functions as an experienced project manager coordinating large-scale singular projects or multiple smaller, less complex projects. Responsibilities may include coordination of Joint Commission, Ohio Department of Health, and other regulatory surveys. Facilitating continuous readiness for regulatory surveys. Facilitating multidisciplinary performance improvement activities. Confers with Risk Management, Nursing, Infection Prevention, Information Technology, and physicians to address regulatory, quality and patient safety concerns. Communicates effectively with multidisciplinary staff.

Responsibilities

The Performance Improvement Specialist - Accreditation serves as the expert resource and expert on regulatory / accreditation and licensure standards and expectations for compliance. Designs and implements a systematic approach to ensure a high level of awareness of regulatory and accrediting agency requirements including ramifications of failures in compliance. This position will guide the development of policies and practices as they relate to the hospital and compliance with regulatory and accreditation guidelines and assists in the interpretation of these standards and regulations.

Essential Job Duties :

• Provides central expertise regarding accreditation and licensure standards. Identifies, plans for, communicates, monitors and evaluates actions to comply with existing and new regulations, standards and accreditation requirements. Ensures timely analysis of regulatory materials, journals and newsletters for implications on operations.
• Provides documentation and other information as required or requested on time to assure compliance for regulating and accreditation agencies. Maintains and organizes all critical documentation support in compliance with requirements to include the development of delivery and follow-up documentation (i.e., reports, plans, appeals, etc.).
• Investigates complaints from the Department of Health, prepares response and reviews with leadership prior to submission.
• Maintains compliance with CMS Conditions of Participation.
• Develops working relationships with external agency representatives and key contacts to assist understanding of hospital compliance requirements.
• Provides leadership for medical center preparation and readiness for regulatory and accreditation surveys. This includes scheduling, logistics and communication necessary for onsite surveyor visits. Serves as the liaison to regulatory agencies and accreditation bodies.
• Provides consultation to all departments on the interpretation and application of The Joint Commission (TJC) accreditation standards to maintain ongoing readiness. Coordinates on-going preparation for Joint Commission survey.
• Chairs Joint Commission Chapter Leader Committee Meetings.
• Reviews Joint Commission website daily for current information and distributes to members of the Joint Commission Readiness team and appropriate Department Directors. Coordinates update of policies and procedures to reflect Joint Commission and CMS changes.
• Coordinates mock and “on-site"" unannounced Joint Commission survey.
• Identify areas of vulnerability and assist area leaders in developing corrective action plans. Provides consultation to all departments on the interpretation and application of TJC accreditation standards to maintain ongoing readiness.
• Assists area leaders in the development of specific educational material to address areas of vulnerability for compliance with standards or unique requirements for special accreditations.
• Identifies and communicates areas of success; celebrate and encourage promotion of best practices.

Educational / Experience Requirements :

Required License / Certifications :

CPHQ certification preferred.

Current licensure as a registered nurse preferred

Qualifications

The Performance Improvement Specialist - Accreditation serves as the expert resource and expert on regulatory / accreditation and licensure standards and expectations for compliance. Designs and implements a systematic approach to ensure a high level of awareness of regulatory and accrediting agency requirements including ramifications of failures in compliance. This position will guide the development of policies and practices as they relate to the hospital and compliance with regulatory and accreditation guidelines and assists in the interpretation of these standards and regulations.

Essential Job Duties :

Educational / Experience Requirements :

Required License / Certifications :

CPHQ certification preferred.

Current licensure as a registered nurse preferred