The Accreditation and Regulatory Readiness Specialist reports to the Director of Accreditation and Regulatory Readiness. Under supervision performs a wide variety of duties in supporting all aspects of The Joint Commission (TJC) accreditation standards and Centers for Medicare and Medicaid Services (CMS) conditions of participation compliance as well as Department of Health (DOH) regulations and other related external regulatory accreditation and certification requirements. Supports communication and education of all involved personnel about accreditation requirements implications and changes across Brown University Health Health System. Supports the Director of Accreditation and Regulatory Readiness key stakeholder groups and ad hoc teams on accreditation and other regulatory-related performance improvement activities. Supports improvement strategies and tactics by working collaboratively with other disciplines within Brown University Health.
Supports the continuous process of self-assessment of Brown University Health compliance and readiness with all TJC CMS DOH and related standards in partnership with stakeholders. Supports ongoing mock survey audits and tracers for compliance with TJC and CMS standards using a project management approach.
Collaborates and coordinates review of selected accreditation and regulatory opportunities with Risk Management Care Transformation Quality and Safety and with other quality initiatives and committees as needed across the Brown University Health Health System.
Supports the Director in managing regulatory and accreditation compliance initiatives. Identifies major phases implementation steps key stakeholders timelines resource needs and potential obstacles or issues for escalation.
Responsible for coordination of monthly accreditation readiness committee including assignment of Joint Commission readiness lead for each chapter. Assists with accreditation assessment and survey preparation-related activities including TJC regular application updates. Supports and maintains accreditation-required policies and required documents for survey.
Monitors overall performance metrics related to regulatory and accreditation standards as assigned and for communicating with internal and external customers related to regulatory and accreditation standards. Prepares readiness synopses and prepares recommendations for prioritization of decisions to Leadership and associated readiness committee meetings.
Ensures TJC and other regulatory compliance by advising departments services and committees of relevant specific accreditation and regulatory interpretations and any changes to previous regulations. Interprets standards for evidenced-based care as required. Provides instruction on TJC regulations and information on models for clinical improvement efforts. Contacts those responsible for reporting data to determine status and collaborates as needed to achieve compliance with program specifications.
Manages development of tools learning aids standard reports and monitoring plans to promote compliance with standards. Conducts tracing activities and document reviews as requested.
Supports the analysis and communication of sentinel event alerts and other similar TJC alerts; maintain current knowledge of patient safety standards including The Joint Commission's National Patient Safety Goals; collaborate with within the organization to assure compliance with such required standards.
Reviews appropriate literature to maintain and enhance knowledge of federal state and voluntary regulatory standards that relate to quality improvement and The Joint Commission/other accreditation requirements. Participates in and supports each Brown University Health affiliate's hosting of regulatory or accreditation personnel visits and any consequent follow-up work reports and/or presentations.
Performs other related duties as assigned.
EDUCATION
A bachelor's degree in health administration nursing or healthcare professional field is required. Advanced degree in related field preferred. Behavioral health background preferred.
EXPERIENCE:
Experience with managing and supporting organizational accreditation (e.g. The Joint Commission CMS) preferred along with knowledge of Behavioral Health. Experience with the principles and practices of health care quality management preferred. Project management experience preferred. Working knowledge of all Microsoft Office software applications required. Minimum of two (2) years of related work experience is also required. Position requires excellent communication skills including the ability to communicate information effectively to others both verbally and in writing. Position duties require the ability to make various presentations internally and externally.
Ability to focus on multiple projects and re-establish priorities as necessary. Ability to facilitate and work within a complex multi-site environment.
WORK ENVIRONMENT AND PHYSICAL REQUIREMENTS:
Work is performed in a typical office setting requiring extensive periods of sitting with arms extended as well as walking and standing.
INDEPENDENT ACTION:
Incumbent generally establishes own work plans and priorities including the development and utilization of appropriate strategies methodologies and activities to assure accurate valid and timely completion of work in conformance with organizational and department policies and practices.
Strong analytical and critical thinking skills.
SUPERVISORY RESPONSIBILITY:
None