ACCREDITATION AND REGULATORY AFFAIRS COORDINATOR - Performance Improvement - Full Time - Days
5 days ago
Porterville
Job Description Accreditation & Regulatory Affairs Coordinator - Full Time Shift: Days, 8:00am - 4:30pm, EXEMPT Job Description: PATIENT POPULATION: The patient population served can be all patients, including geriatric, adult, adolescent, pediatric, and newborn. This also includes services which affect facility staff, physicians, visitors, vendors and the general public. POSITION SUMMARY: Reporting to the Vice President of Quality and Regulatory Affairs, the Accreditation and Regulatory Affairs Coordinator is responsible for duties related to Organizational Performance Improvement and Regulatory compliance. This includes, but is not limited to, coordinating regulatory surveys and ongoing survey preparedness. Supports high quality, safe care by ensuring organizational systems and processes comply with all regulatory requirements. Is responsible for communicating, maintaining and processing defined or designated confidential Performance Improvement information. Will assist the VP with educational opportunities related to survey readiness. Must be professional and cooperative with patients, visitors, employees and members of the medical staff, in support of the hospital's customer service goals. Must be able to work normal/scheduled working hours to include Holidays, call-backs, weeknights, weekends, and on-call. Agrees to participate, as directed, in emergencies and community disasters during scheduled and unscheduled hours. As a designated disaster service worker you are required to assist in times of need pursuant to the California Emergency Services Act. (Gov’t. Code §§ 3100, 3102) Needs to recognize that they have an affirmative duty and responsibility for reporting perceived misconduct, including actual or potential violations of laws, regulations, policies, procedures, or this organization’s standards/code of conduct. The employee shall work well under pressure, meet multiple and sometimes competing deadlines; and the incumbent shall at all times demonstrate cooperative behavior with colleagues and supervisors. EDUCATION/TRAINING/EXPERIENCE: Must have Bachelor's degree in a health related field. Prior experience of at least 2 yrs with survey readiness and accreditation related activities is required. Demonstrates independent judgment, autonomy and initiative in leadership skills, time management and organizational skills and the ability to prioritize projects/functions in a busy work environment. To perform this job successfully, the individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals. Ability to write routine reports and correspondence if required. Effective and diplomatic oral and written communication skills and maintenance of confidential information. Ability to calculate figures and amounts such as discounts, interest, commissions, proportions, and percentages if required. Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form. Ability to deal with problems involving several concrete variables in standardized situations. To perform this job successfully, an individual should be computer literate in programs such as Microsoft Word, Excel and Power Point. Able to create statistical reports, using graphs and charts to present data. LICENSURE/CERTIFICATIONS: Bachelor's degree in health care related field required. Responsibilities and Essential Functions: *Indicates Essential Function 1* Along with the VP, provides oversight for all licensure, regulatory and accreditation efforts throughout the Organization. 2* Collaborates with hospital departments to formulate corrective plans which correlate to the identified opportunities for improvement. 3* Continually, analyses and interprets changes in legislation and requirements related to regulatory, accreditation and licensure issues. Provides reports to leadership and VP indicating organizational needs and compliance as it relates to these updates. 4* Manages and reports on the ongoing professional practice evaluation process (OPPE) which ensures the timely data collection of information professional practice trends that may impact the quality and safety of care. ACCREDITATION 1* Coordinates all processes related to survey readiness activities including: Focused Standards Assessment (FSA), Tracers, Chapter teams and unannounced response plans. 2* Coordinates all activates related to licensure readiness by overseeing accreditation and regulatory readiness teams and committees, related to new business lines & hospital expansions 3* Serves as an interface with regulatory/accrediting agencies in promoting compliance with standards. 4* Interprets regulatory standards and demonstrates current knowledge of local, state, and national standards/codes/regulations via use of appropriate resources. 5* Develops and manages a comprehensive system for assessing organizational compliance and risk based upon clinical quality data and outcomes, concurrent observation of practices, tracer findings, mock survey findings, and actual survey findings. 6* Performs and manages the system for environmental scanning (monitors websites, updates, newsletter, etc.) to proactively address new and revised standards, survey changes and future accreditation implications. 7* Manages an effective organization-wide communication system related to all relevant survey related information including but not limited to the survey process, survey process changes, compliance results, new and revised standards. 8 Provides organization-wide oversight and works collaboratively with Disease Specific Care Certification program liaisons to ensure all accreditation and survey process requirements are met. 9* Is responsible for the administration and oversight of the Policy Management System. Oversight includes: • Supports and maintains PowerDMS application and modules, mapping and building for all Folders, User Security, and Reports., • Audits populated data to ensure integrity of documents., • Design and deliver routine reports and responds to ad hoc report requests., • Collaborate with Administrative Users to identify system improvements and enhancements., • Oversee system upgrades and build-outs of new process' to the system i.e. , MIFU, Forms and SOP's., • Training support to all Administrative Users and all newly hired staff who are Document Owners. Ensures program maintenance, education, and ongoing system implementation of all elements of the platform to ensure document acuracy and ease of access to end-users." 10* Demonstrates competence in Performance Improvemeny Methodology. 11 Independently facilitates accreditation to survey readiness TECHNICAL /CLINICAL DUTIES/RESPONSIBILITIES/ACCOUNTABILITIES: • Assists in the collection, analysis and tracking of statistical data to identify trends and or opportunities for improvement. Related to survey readiness and regulatory compliance., • Organizes time and workflow to complete job responsibilities in an accurate and timely manner.