OMMUNITY HOSPITAL JOB DESCRIPTION

Accreditation & Regulatory Compliance Manager

POSITION SUMMARY

Under the direction of the Chief Nursing Officer or designee, The Accreditation & Regulatory Compliance Manager is responsible for evaluating and monitoring hospital compliance with regulatory requirements and accreditation standards as assigned.

The Accreditation & Regulatory Compliance Manager is responsible for working with Mission Community Hospital’s (MCH) leadership, hospital staff, physicians, and mid-level providers to assess, plan, improve and maintain compliance with regulations set forth by the California Department of Public Health, Center for Medicare/Medicaid Services (CMS) and contracted Accrediting Organizations. The Accreditation & Regulatory Compliance Manager acts as a resource for the medical staff, executive leadership, and hospital staff. In addition, this position has the accountability for organizational compliance associated with all Disease Specific Certification.

This position requires the full understanding and active participation in fulfilling the mission of MCH. The Accreditation & Regulatory Compliance Manager is expected to demonstrate behavior consistent with the MCH’s values and shall support its strategic plan, goals and direction of the hospital survey readiness performance plan.

MAJOR RESPONSIBILITIES

SERVICE PERFORMANCE

Greets/acknowledges customers warmly, with a smile, and immediately when they enter department/unit/area.
Asks how the customer may be helped with interest and concern.
Listens attentively, does not interrupt.
Accepts ownership and takes action to resolve customer needs and/or concerns.
Is attentive and responsive to the expectations of physicians, co-workers and direct reports.
Accepts constructive criticism and modifies actions accordingly.
Is generous in acknowledging a job well done.
Uses words and behaviors that express consideration, concern and respect.
Facilitates and holds leadership accountable for meeting department customer service standards in the performance of duties.
Utilizes telephone skills effectively as outlined in the Star Service Program.
Keeps all private information about staff or patients confidential.
Identifies customers and their service requirements.
Meets or exceeds customer service improvement targets as demonstrated by dashboards, etc.

VALUE ADDED – INCREASES WORTH OF SERVICE TO MISSION COMMUNITY HOSPITAL

Engages in interdepartmental /multi-department/house-wide process improvement forums/task forces/committees.
Offers and implements solutions to challenges/problems.
Assist with development-related activities including fund raising programs & activities.
Attends/participates in activities that contribute to professional growth and development.

PRIMARY POSITION RESPONSIBILITIES

Responsible for conducting daily and ongoing clinical and system tracer activities to ensure accreditation standards and regulatory requirement compliance. Priority tracer activities include:

Assessment and Reassessment - Tracer
Falls Assessment - Tracer
Blood Transfusion Tracer
Pain Assessment and Reassessment - Tracer
Clinical Alarm Safety - Tracer
Clinical Alarm Safety Telemetry - Tracer
Hand Hygiene -Tracer
Grievance Process

Additional tracer activities will be assigned by the Medical-Surgical Nursing Director and/or the Chief Nursing Officer or designee as indicated.

Functions as accreditation and regulatory compliance auditor, conducting internal and focused audits as needed; and serving as facilitator on Corrective Action Teams to resolve non-compliant standards and elements of performance.

Collects, trends, reports and displays mock tracer findings using AMP Tracer software.

ADDITIONAL POSITION RESPONSIBILITIES

Assist with developing, implementing, maintaining and improving hospital pre-survey activities that foster collaboration among all disciplines involved in the care of all patient populations served.

Monitors performance measures for assigned Joint Commission specialty certification programs to ensure compliance and improved program outcomes.
Assist with coordination, facilitation and participation in pre, post, and on-site survey activities, this includes but is not limited to: survey agenda preparation, interaction with surveyors, coordination of survey readiness activities, and provide role specific guidance to facilitators, scribes, and hospital executives, physician and nursing leadership; provides survey education to hospital staff; facilitates exit conferences and communication of findings as well as assisting in the development of Corrective Action Plans for non-compliant findings and the implementation and follow up of same; and evaluation of effectiveness of implementation and sustainability of resolution and corrective action plan processes.
Remains current with regulatory changes by attending conferences and seminars and by reviewing professional journals, as well as communicating changes or newly developed standards, requirements, and clauses to appropriate staff, departments and leadership, as indicated.
Ensure hospital is continuously prepared for accreditation and regulatory surveys.

Collaborates and effectively communicates with a wide variety of disciplines within the organization to evaluate, improve, and sustain performance improvement initiatives while serving as a resource for those efforts.
Assists with the resolution of investigations resulting from accreditation complaint follow-up surveys.
Responsible for evaluating and reporting hospital-wide accreditation and regulatory survey readiness activities/initiatives including patient satisfaction improvement initiatives.
Recommends changes in the administrative policies that conform to accreditation standards and California/Federal regulations.
Assist with developing and implementing policies and procedures that support the provision of services and adherence with regulatory and accreditation standards.
Submits accurate and timely status reports to the Survey Readiness Workgroup and/or hospital committees as directed.

Identifies trends and displays opportunities for hospital, medical, department/unit care and/or service improvement via aggregation of data, information, and indicators.

Performs other duties as related to position or assigned.

COMPLIANCE

Reports, promptly, any suspected or potential violations to laws, regulations, procedures, policies and practices, and cooperates with investigations.
Conducts all transactions in compliance with all corporate and medical center policies, procedures, standards and practices.
Facilitates/fosters compliance with all applicable laws, regulations, procedures, policies and practices required by the job, based on the scope of practice of the position.
Facilitates identification and reporting of occurrences of potential liability to the Hospital.

INFORMATION MANAGEMENT

Uses information sources appropriately in department/unit operations.
Uses department specific information systems applications efficiently and effectively.
Accesses and creates department specific information system application reports.
Conducts reality and validation assessments of data processed by the department.
Serves as an effective resource to IS to ensure accurate entry/updating of department specific systems applications.
Complies with hospital policies, accreditation agency standards and state and federal confidentiality requirements related to management of information, including HIPAA.
Obtains necessary training prior to initial equipment and software use.
Uses software at an intermediate to advanced level.

QUALIFICATIONS

Registered Nurse License in the State of California preferred.
Minimum of three years acute care adult, critical care, or emergency nursing experience preferred.
Three years accreditation and survey experience in acute care hospital setting.
Knowledge of state and federal regulatory and Joint Commission accreditation requirements as they relate to performance improvement and patient safety preferred.
Excellent English written/verbal communication skills.
Proficient computer skills and experience using Microsoft Word and Microsoft Office software.
Current BCLS Certification

Current Fire Card certification

Special Knowledge, Skills, and Abilities Required

1. Strong knowledge of process improvement tools and techniques.
2. Strong interpersonal skills and demonstrated ability to work with multidisciplinary groups and

teams.
3. Skilled in verbal and written communication.
4. Ability to analyze and solve problems.
5. Ability to work independently and interdependently.
6. Appreciation of cultural diversity and sensitivity.
7. Proven time management skills and able to meet deadlines.

Work Environment
1. Normal office conditions.
2. Prolonged sitting, standing, or walking may be required during shift.
3. Use of computer, standard office equipment, and hospital survey software.