Position Summary:

Serves as an expert resource and expert on regulatory / accreditation and licensure standards and expectations for compliance for Crozer Keystone Health System Hospitals and satellite facilities. Designs, implements, and facilitates a systematic approach to ensure a high level of awareness of regulatory and accreditation agency requirements. Provides education to the leaders, medical staff, patient care services and ancillary departments to promote compliance activities. .

Provides education and serves as a resource to medical staff, leaders, and staff on The Joint Commission standards, Pennsylvania Department of Health, CMS regulations, and other regulatory bodies as applicable to the hospital.

Maintains knowledge of accrediting and regulatory agencies' standards on a continual basis to identify changes in current requirements and any new/ additional mandates; communicates updates to & coordinates compliance with the appropriate chapter leader

Supports the hospital's survey readiness program:

• Chapter leader education and facilitation
• Committee meeting and structure
• the annual self-assessment process
• Action plan and monitoring
• Leader and staff education
• Monitoring of compliance with chart audits, tools such as tracers, rounds, mock surveys
• Host surveyors when onsite and participate in phone conferences as required for licensure and accreditation
• Communicates with Accrediting/Regulatory agencies regarding survey planning, preparation, and responses.

Compiles and communicates survey readiness activity results to the chapter leaders and hospital structure. Also facilitates follow up completion to ensure appropriate corrective action is taken.

Maintains and coordinates system-wide Environment of Care (EOC) rounding schedules and follow up activities. This includes utilizing specialized software designed to track and report EOC data.

Maintains the following for survey visits:

• Policy
• Notification process
• Maintains and organizes documentation support
• Website maintenance of required information

Coordinates corrective action plans and monitoring activities in response to survey reports and requirements within the required time frames

Maintains confidentiality of all information as well as the release of any information.

Participates in continuing education relevant to Joint Commission standards, Pennsylvania Department of Health and CMS regulations.

Maintains licensure and/or certification as required by job requirements and provides documentation

Assist the Director of Accreditation and Regulatory Services with special projects as needed

Education and Training:

BS in Healthcare field

Experience:

Three to five years related Healthcare Accreditation or Quality experience.

Registration, Licensure and/or Certification:

Joint Commission Professional or Quality Certification preferred. RN Preferred.

Skills:

Must have advance knowledge of Microsoft Office programs including Outlook, Word and Excel.

Working knowledge of quality improvement and problem solving tools and techniques required.

Excellent interpersonal skills, ability to teach, understanding of patient safety issues, Joint Commission National Patient Safety Goals, knowledge of Joint Commission standards