Sr Specialist | Licensing & Accreditation | Regulatory Affairs | Sharp Memorial Hospital | FT Days

Sharp HealthCare•San Diego, CA

18h•Onsite

About The Position

The Senior Specialist–Performance Improvement-Licensing and Accreditation is responsible for the development and implementation of performance improvement standards with a primary emphasis on regulatory affairs, licensing, accreditation, risk management, patient safety, and adverse event reporting across multiple hospitals. The role supports hospital‑wide and system‑level performance improvement through the utilization of Change Acceleration Process (CAP), Lean, Six Sigma, and other performance improvement tools, and provides analytic feedback to managers, directors, physicians, and executives. This role serves as a key multi‑hospital liaison between operational leaders and regulatory and accreditation agencies during survey preparation, response, and follow‑up, working in close alignment with the Director of Licensing and Accreditation, Multi‑Hospital, and the Manager of Licensing and Accreditation, Multi‑Hospital. The Senior Specialist works collaboratively with operational leaders, quality, patient safety, risk management, and system partners to support improved clinical outcomes, operational performance, regulatory compliance, and patient safety. This position is responsible for data analysis and reporting to leadership teams, committees, and governing boards to support compliance with regulatory requirements, laws, and hospital policies and procedures. This role assists hospital service lines and operational areas in identifying actual and potential performance, quality, safety, and compliance risks through measurement and analysis, including concurrent and retrospective review of performance information. The position supports operational planning and development of multi‑hospital performance improvement and quality/safety plans and supports compliance with requirements set by regulatory and accreditation agencies.

Requirements

Bachelor's Degree in nursing or an appropriate healthcare‑related field.
5 Years acute care hospital operational experience.
5 Years experience in performance improvement, quality, patient safety, regulatory affairs, or risk management.
Experience with data analysis, case review, adverse event investigation, and regulatory compliance.
If clinically licensed, the license must be current, valid and unencumbered in California.
Current knowledge of Joint Commission, state, and federal regulatory agency requirements, standards, and regulations.
Intermediate to advanced computer skills including word processing, spreadsheets, databases, and presentation programs.
Advanced analytical, problem‑solving, and critical‑thinking skills.
Ability to work effectively with executives, management, staff, and physicians and communicate clearly in writing and verbally.
Maintains confidentiality of hospital, quality, safety, and regulatory information.

Nice To Haves

Master's Degree in a related field.
Experience supporting multi‑hospital or system‑level initiatives.
Six Sigma Green Belt Certification

Responsibilities

Development and implementation of performance improvement standards with a primary emphasis on regulatory affairs, licensing, accreditation, risk management, patient safety, and adverse event reporting across multiple hospitals.
Support hospital‑wide and system‑level performance improvement through the utilization of Change Acceleration Process (CAP), Lean, Six Sigma, and other performance improvement tools.
Provide analytic feedback to managers, directors, physicians, and executives.
Serve as a key multi‑hospital liaison between operational leaders and regulatory and accreditation agencies during survey preparation, response, and follow‑up.
Work collaboratively with operational leaders, quality, patient safety, risk management, and system partners to support improved clinical outcomes, operational performance, regulatory compliance, and patient safety.
Data analysis and reporting to leadership teams, committees, and governing boards to support compliance with regulatory requirements, laws, and hospital policies and procedures.
Assist hospital service lines and operational areas in identifying actual and potential performance, quality, safety, and compliance risks through measurement and analysis, including concurrent and retrospective review of performance information.
Support operational planning and development of multi‑hospital performance improvement and quality/safety plans.
Support compliance with requirements set by regulatory and accreditation agencies.
Utilizes independent judgment, training, and experience to recognize variances in hospital performance, regulatory compliance, and patient safety performance and identifies opportunities for improvement.
Identifies statistical trends in data through analysis of key operational metrics, adverse events, case reviews, system reviews, and/or clinical data.
Conducts accurate, comprehensive, and systematic reviews of facility and service line performance using concurrent and retrospective data.
Manages data and expert analyses supporting hospital‑wide and multi‑hospital quality, safety, regulatory compliance, and performance initiatives.
Determines and applies appropriate performance improvement processes including Change Acceleration Process (CAP), Lean, Six Sigma, and DMAIC to support improvements in entity, department, and multi‑hospital performance.
Participates in and supports performance improvement projects, root cause analyses (RCAs), and failure mode and effects analyses (FMEAs) related to quality, safety, and regulatory compliance.
Collaborates with hospital and system leaders to support achievement of organizational, departmental, and multi‑hospital performance improvement objectives.
Uses ongoing monitoring techniques and data analysis to support sustainment of improved processes.
Supports multi‑hospital regulatory readiness and ongoing compliance with Joint Commission, CDPH, CMS, and other applicable regulatory and accreditation agencies.
Participates in preparation for licensing, certification, and accreditation surveys across hospitals, including document development, coordination, and response to findings.
Assists with development, implementation, and monitoring of plans of correction and regulatory follow‑up activities in coordination with system licensing and accreditation leadership.
Interprets regulatory requirements and incorporates standards into performance improvement initiatives and operational practices.
Collaborates with Quality, Patient Safety, Risk Management, and Clinical leadership to support management of adverse events, near misses, sentinel events, and regulatory reportable events across hospitals.
Ensures timely reporting, analysis, and follow‑up of adverse events in accordance with regulatory and organizational requirements.
Participates in RCAs, FMEAs, and system reviews to identify system failure modes and improvement opportunities.
Conducts effective interviews with staff and providers involved in safety events using just culture principles.
Demonstrates strong verbal and written communication skills, presentation skills, and professionalism with individuals at all levels of the organization.
Works collaboratively with hospital and system leaders, physicians, quality, risk management, and system partners to support organizational and multi‑hospital goals.
Provides education and technical support related to performance improvement, regulatory compliance, accreditation standards, and patient safety.
Assumes responsibility for ongoing professional development and maintains knowledge of regulatory requirements and industry best practices.