Develops and implements organizational initiatives to support accreditation and regulatory continuous readiness. The scope of a well-developed program encompasses 1) Standard interpretation, 2) Standard compliance, 3) Education and communication, and 4) Survey operations. Promotes a continuous readiness program that emphasizes quality and patient safety at the forefront of regulatory compliance. Oversees the day-to-day program operations and workflow.
This position will not have any direct reports.
NATURE AND SCOPE
Interacts with Quality Staff, Chief Medical Officer, physicians, nurses, other healthcare providers and Hospital and University officials.
- Assist Director of QA with continuous readiness efforts and other aspects of quality and PI.
- Proactively leads the ongoing evaluation, planning and support of the continuous readiness infrastructure and processes to ensure Joint Commission accreditation and other regulatory accreditation, certifications, and applicable organizational licenses.
- Collaborates with Compliance, Risk Management, Patient Safety, Infection Prevention and Control and other departments to delineate regulatory responsibilities.
- Identifies regulatory vulnerabilities and collaborates with hospital departments to identify corrective action plans
- Leads organization-wide accreditation and regulatory compliance initiatives.
- Develops and manages the meetings and activities of the Joint Commission Compliance Committee.
- Provides guidance on Joint Commission standards, CMS COP’s interpretation and other regulatory requirements as they apply to organizational practice.
- Develops education and reference materials and provides presentations at manager meetings. • Develops and implements initiatives to evaluate and monitor compliance with Joint Commission and other regulatory standards through ongoing, organizational assessment, i.e. Intracycle Monitoring, Focused Standards Assessment, tracers, mock surveys and measurement data.
- Tracks and maintains The Joint Commission accreditation plan
- Oversees the development of an organizational communication and education plan for Joint
- Commission accreditation.
- Serve as an organizational resource and leader in accreditation and regulation
- Serves as contact and point person for Joint Commission accreditation manuals, standards-related publications and newsletters and educational materials; ensures pertinent information is communicated to appropriate individuals.
- Serves as a resource to content experts and executive sponsors in regulatory standard interpretation, insight on upcoming regulatory changes, new requirements, along with exploring options for operationalizing requirements.
- Serves as an expert resource and leader to the accreditation and regulatory specialists, content experts, executive sponsors, medical staff leaders, directors, managers and staff in regards to The Joint Commission accreditation and other regulatory activities and process. • Plan and coordinate the accreditation and/or regulatory survey
- Serves as a liaison between accreditation I regulatory bodies and the organization. Develops, maintains, and implements organizational Unannounced Survey Plan.
- Assists in triaging onsite TJC and other agency onsite activity.
- Oversees organizational wide announcements and communications related to onsite surveys including the initial announcements, daily updates, and concluding remarks.
- Manages onsite accreditation and regulatory surveys; directs command center activities.
- Manages communications, agendas, and logistics for onsite survey activities. • Services as liaison between onsite surveyors and organization
- Manage all ongoing application requirements and corrective action plans
- Provides expertise and leadership in the development and implementation of action plans including measurement support as needed, for required follow up from Joint Commission and other regulatory surveys and Intracycle Monitoring.
- Finalizes and submits corrective action responses to The Joint Commission and other regulatory agencies for survey and for-cause and compliant investigations.
- Collaborates with content experts and executive sponsors to ensure corrective action plans are implemented, measures are in place and monitored to sustain accreditation
- Assumes other duties and responsibilities that are related and appropriate to the position and area. The above responsibilities are a general description of the level and nature of the work assigned to this classification and are not to be considered as all-inclusive.
- Promotes adherence to the Health Sciences Compliance Program, the Howard University Code of Ethics, the Health Sciences Standards of Conduct and Health Insurance Portability and Accountability Act (HIPAA).
- Attends annual and periodic mandatory Compliance Program training including the Health Insurance Portability and Accountability Act (HIPAA) Privacy training.
- Participates in activities that promote adherence to federal healthcare program requirements.
- Actively participates in Health Sciences Compliance Program activities.
- Maintains confidentiality of patients, families, and staff.
- The employee must demonstrate collaboration, accountability, respect, excellence, and service.
- The employee must work with team members and peers in and outside of their immediate work group to create an exceptional experience for patients, students and other visitors.
- The employee must accept responsibility for their actions to provide health care and/or ancillary functions in a highly efficient and compassionate manner. The employee must function as a Steward (Have Ownership) of the Howard University Hospital values that foster a commitment to improving the patient and student experience, organizational efficiency and the environment.
- The employee must embrace diversity and care holistically for those Howard University Hospital serves. They must treat all as they would like to be treated. They must manage the patient’s right to privacy and keep any proprietary information about the institution confidential.
- The employee must anticipates the needs of the patient and/or student. They must present themselves as a model representative of the institution and maintains high standards of care while striving to improve performance and create exceptional experiences for our patrons.
- The employee must behave in a friendly, resourceful and professional manner towards all individuals they encounter.
- Knowledge of quality management regulations in the Healthcare Industry.
- Ability to establish and maintain a relationship with all employees, public and private organizations, and regulatory agencies.
- Ability to work under pressure
- Ability to provide exceptional customer service
- Proficient in Microsoft Word, Excel, Powerpoint and Visio
- Competence in both oral and written English.
- Ability to establish and maintain effective and harmonious work relationships with staff, physicians, Hospital and University officials, and the general public.
- Bachelor's degree in Nursing or a related field, or equivalent combination of experience and education.
- Registered Nurse
- Minimum of 3-5 years' accreditation experience working in the healthcare industry. Prior leadership training, classes or experience.
- Leadership skills Knowledge of TJC Standards and regulatory compliance issues.
- Experience applying quality management/performance improvement and customer service approaches
- Excellent verbal and written communication skills.
- Must be able to stand, walk, sit, lift (up to 50lbs), bend, write, type, file, speak, hear, see, calculate, compare, edit, evaluate, interpret and organize for extended periods of time