Quality Regulatory & Accreditation Specialist, Full Time Days

Stanford Health Care Tri-Valley • Dublin, CA

5d • $76 - $101 • Onsite

About The Position

The Quality Regulatory & Accreditation Specialist is responsible for planning, coordinating, monitoring, and improving the accreditation, regulatory, & licensure compliance of clinical care and services at the hospital. This position is responsible for leading multiple small to medium scale, service or unit specific, performance improvement initiatives. This role combines the acumen required to change practice with the leadership skills to influence clinical processes, systems, and outcomes. This position will assess and develop ongoing compliance strategies within the system of care. The Quality Regulatory & Accreditation Specialist identifies opportunities for unit/service-based improvements based on evidence-based practices, regulatory and accrediting agency requirements, and data analysis of high risk, high volume and/or problem prone processes. This position is responsible for negotiating timelines and priorities for projects, coordinating action plans, and monitoring/analyzing results for projects that are consistent with the unit/service strategic goals which should be aligned with the organizational quality imperatives.

Requirements

• Minimum associate’s degree in nursing required
• Minimum three (3) years of healthcare experience, including clinical nursing experience.
• Ability to utilize the quality improvement framework to ensure that performance improvement initiatives focus on improving outcomes, appropriateness of care, patient centeredness, and value.
• Ability to coordinate project initiatives, meetings, and clinical program management to achieve service and unit specific goals and strategic direction.
• Knowledge of change management tools/techniques and is able to apply them to projects.
• Knowledge of and ability to apply performance improvement methodologies and tools to projects (e.g., Lean, Six Sigma, proactive risk assessments, and Root Cause Analysis).
• Knowledge of quantitative skills and ability to use statistics to evaluate and interpret data, summarize results and make recommendations.
• Knowledge of project management and change management methodologies and tools.
• Ability to understand and use structure to drive process changes and how to use processes to drive towards desired outcomes.
• Ability to work collaboratively in a multi-disciplinary environment.
• Ability to demonstrate sound judgment, reasoning, and detail oriented.
• Ability to understand and use information technology to drive process changes.
• Ability to influence effectively to create synergy, prioritize projects, set goals and actions plans, and measure impact.
• Ability to stay abreast with California Title 22 and Health and Safety Code regulations, Joint Commission Hospital and Laboratory accreditation standards, Joint Commission’s Disease –specific Care Certification, and Medicare CMS Conditions of Participation (specifically Appendix A).
• Expert proficiency with web-based tools, including Survey monkey, and Joint Commission’s e-Application.
• RN - Registered Nurse - State Licensure And/Or Compact State Licensure required

Nice To Haves

• Experience in hospital accreditation, regulatory compliance, licensure, quality, patient safety, or performance improvement is preferred.

Responsibilities

• Co-facilitates local, state, and federal clinical regulatory and accreditation activities for Stanford Health Care Tri-Valley to ensure that clinical services are provided in accordance with established standards.
• Performs, coordinates, and co-facilitates ongoing accreditation and regulatory readiness and quality improvement initiatives for assigned projects to achieve unit/service goals, working collaboratively with leaders, physicians, and staff of designated unit/service.
• Responds to on-site surveyors and regulatory agencies related to patient care matters. Meets surveyor when they arrive on site. Function as a host and/or escort to accreditation and regulatory surveyors who come onsite to conduct compliance assessment and investigation. This role may also be involved co-managing a survey command center and developing and managing plans of corrections.
• Notifies appropriate departments that their area may be visited when the regulatory or accreditation surveyors arrive and is responding to a patient care complaint, never-event notification, or survey.
• Working with ACNO Patient Safety, Accreditation, and Nursing Excellence to submit reports to agencies as indicated after serious adverse event or unusual occurrence.
• Performs data analysis; creates & interprets data displays. Works collaboratively with Clinical and Support Services, senior and middle management, Compliance, Office of General Counsel, Risk Management, Information Technology, and others to ensure the integrity and accuracy of the data that is utilized. Utilizes Microsoft programs, RLDatix, applicable Joint Commission web-based applications, online survey/assessment tools, and other applications & databases.
• Evaluates data, makes judgments, and recommendations regarding accreditation and regulatory work, including but not limited to results from mock and real surveys, assessments, and information from internal/external consultants, as well as accreditation and/or regulatory reviewers. Designs and develops dashboards and other innovative data visualization using business intelligence tools.
• Provides content knowledge in the interpretation, implementation, and maintenance of standards to match external requirements (e.g., Joint Commission, CMS Conditions of Participation, California Title 22 and Health and Safety Codes)
• Prepare and maintain documentation for continuous California Department of Public health hospital licensure and notification requirements.
• Assist with the development and revision of the hospital’s policy manual and functions as a consultant to the organization on policy management.
• Employee must perform all duties and responsibilities in accordance with the C-I-CARE Standards of the Hospital. C-I-CARE is the foundation of Stanford Healthcare Tri-Valley’s patient-experience and represents a framework for patient-centered interactions

Benefits

• Stanford Health Care sets a high standard for delivering value and an exceptional experience for our patients and families. Candidates for employment and existing employees must adopt and execute C-I-CARE standards for all of patients, families and towards each other. C-I-CARE is the foundation of Stanford’s patient-experience and represents a framework for patient-centered interactions. Simply put, we do what it takes to enable and empower patients and families to focus on health, healing and recovery.
• You will do this by executing against our three experience pillars, from the patient and family’s perspective: Know Me: Anticipate my needs and status to deliver effective care Show Me the Way: Guide and prompt my actions to arrive at better outcomes and better health Coordinate for Me: Own the complexity of my care through coordination

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree