Accreditation and Regulatory Compliance (ARC) Coordinator - FT - Day

Frederick Health•Frederick, MD

1d•Onsite

About The Position

Responsible for comprehensive health system efforts to maintain continuous compliance with regulatory requirements including Joint Commission standards, National Patient Safety Goals, CMS Conditions of Participation, Maryland COMAR, and other regulatory agencies. Educates hospital staff on regulatory requirements and ensures compliance. Works with Joint Commission chapter leaders to initiate, develop, and monitor compliance requirements. Promotes a safe, functional, and supportive environment within the health system to preserve quality care and safety. Assists Health System’s staff to remain in a state of continual readiness for any regulatory survey. Facilitates and/or supports other quality initiatives of the Accreditation and Regulatory Compliance Division, including Root Cause Analysis and Failure Mode and Effects Analysis. Ensures compliance with CMS complaints, Department of Health, Office of Health Care Quality Complaints, and Joint Commission Complaints. This position supports the Frederick Health mission, vision, core values, and customer service philosophy and adheres to the Frederick Health Compliance Program, including following all regulatory requirements and the Frederick Health Standards of Behavior.

Requirements

Strong clinical knowledge and critical thinking skill to evaluate appropriateness of clinical practice.
Excellent communication skills, both verbal and written.
Strong organizational skills and ability to prioritize and manage multiple tasks.
Interacts with physicians, nurses, department heads, and others while identifying quality of care issues.
Applies creative problem solving, identifies errors of omission, and utilizes resources effectively.
An understanding of CMS and Joint Commission regulations.
Ability to abstract data from the medical record and enter data into designated software programs such as Premier, QME, NDNQI and Verge.
Proficiency and accuracy in the use of software programs such as MS Word, Excel, and Outlook.
Expert knowledge of job/department specific software programs, such as Premier and NDNQI.
Good working knowledge of the internet.
Works professionally with a diverse population base.
Maintains a high level of confidentiality.

Nice To Haves

Previous experience in performance improvement activities including project planning and team facilitation preferred.

Responsibilities

Acts as point person for tracer process, ensuring it meets TJC standards.
Designs, executes, and compiles data regarding mock surveys and tracer activities.
Interacts/interfaces with all members of the medical staff, nursing, and ancillary departments to discuss pertinent issues and follow-up of patient events.
Informs and educates health care leadership, management, and staff about regulatory compliance rates, standards, changes in protocol, and implications to practice.
Maintains current knowledge of TJC, CMS, COMAR, Magnet, and NDNQI and assesses compliance throughout the organization.
Performs retrospective and concurrent review of specific focused studies (including procedures, diagnosis, and other studies) requested by medical staff, hospital departments, and committees.
Provides continued improvement consulting services to customers.
Collects, interprets, and reports data at specified intervals with 99% accuracy and completeness.
Identifies and interprets objective and subjective data found in the medical records.
Compares identified data to established criteria to determine appropriateness of care.
Abstracts and reports performance improvement information in appropriate format to detect patterns and/or problems in the delivery of care.
Identifies potential areas for change and improvement of study design and data collection and makes recommendations.
Develops new ongoing quality projects and evaluates the appropriateness of indicators and criteria for quality monitoring.
Maintains current knowledge of performance improvement strategies, principles, methodologies, techniques, and data analysis.
Executes effective improvement projects through multidisciplinary team collaboration.
Active participant in meetings, providing reports and information as required by the committee or team, and meets 90% attendance.
Assures that issues are communicated to appropriate committees or individuals and that issues have timely resolution.
Expert in knowledge of types of cases that constitute Level I reportable events to the Maryland Office of Health Care Quality.
Notifies the Manager of ARC or Patient Safety Officer regarding reportable or potentially reportable events in a timely fashion.
Facilitates and manages RCA’s and FMEA’s.
Facilitates and manages the investigation of reportable or potentially reportable events.
Facilitates teams to identify areas of potential breach of patient safety and create solutions to eliminate such breaches.
Investigates complaints, including literature research, medical record review, consultation with content experts, and interviews with involved staff/providers.
Processes complaints in accordance with CMS, OHCA, and The Joint Commission established time frames and requirements, developing a written response to each element of the complaint.
Makes referrals to appropriate personnel, interacts with physicians, hospital staff, hospital leadership, and the patient in securing resolution to issues.
Coordinates with Risk Manager on any potentially litigious situation identified during complaint investigation.
Develops and coordinates presentations of complaint activities for appropriate committees and departments regarding trends in the organization.
Coordinates requests for information from the Department of Health and Mental Hygiene, CMS, TJC, or third-party payers related to patient/family complaints.
Overall organization, planning, and controlling of all facility safety-related initiatives and activities.
Develops and conducts formal training and works with departments to develop and conduct training programs; helps to ensure a culture of safety.
Other Duties as assigned