Summary

POSITION SUMMARY:   The Hospital Regulatory Compliance & Accreditation Specialist directly reports to the LifeBridge Health Director of Accreditation and Regulatory Readiness. The Hospital Regulatory Compliance & Accreditation Specialist is responsible for leading hospital and system-wide activities to evaluate and improve adherence to The Joint Commission (TJC) accreditation standards and CMS Conditions of Participation (CoPs) as well as other state and federal regulatory agencies. This includes facilitating and ensuring ongoing readiness for accreditation surveys as well as regulatory complaint investigation surveys.   ESSENTIAL FUNCTIONS:

Regulatory Accreditation & Certification: Responsible for organizing, managing, and facilitating programmatic initiatives related to maintaining Joint Commission (TJC) Hospital Accreditation & CMS Hospital Certification.

Establish and sustain organization-wide processes and systems to maintain compliance with The Joint Commission (TJC) standards, Center for Medicare and Medicaid Services (CMS) Conditions of Participation, COMAR regulations, and State Agency - Office of Healthcare Quality (OHCQ) requirements, etc. Establish and maintain a hospital-wide system to track and maintain accreditations, certifications, and designations for the hospital in collaboration with department leaders and program coordinators. Maintains knowledge of current and up-coming regulatory requirements. Routinely reviews and makes recommendations for policies and procedures relevant to accreditation and certification. Serves as liaison to regulatory and accreditation bodies, providing documentation and information as required or requested on time. Provide regulatory planning support for initiatives related to the development and implementation of clinical and administrative programs throughout our hospital. Assists with external regulatory agency reviews & on-site surveys as needed. Ensure compliance with regulatory requirements including meeting deadlines for data submission and corrective action plan submissions.

Promotes Regulatory Readiness: Fosters a culture of continuous regulatory and survey readiness through a variety of on-going regulatory readiness activities.

Maintains professional knowledge of regulatory requirements, routinely attends webinars and conferences to stay abreast of best practices and serves as a resource for interpretation of regulatory accreditation standards. Interprets relevance of standards in relation to hospital policies and practices. Maintains awareness of changes in regulatory standards and disseminates pertinent information to the respective leadership, key stakeholders, and staff. Conducts patient and system tracers in survey-able areas through observation of practice and the physical environment, by reviewing policies, procedures, documents, staff files, etc. and by conducting interviews. Actively partners with the assigned LifeBridge Health Chapter Chairs and organizational leaders to proactively evaluate compliance with regulatory requirements and identify what PI efforts are being implemented to achieve compliance. Serves as a regulatory consultant and participates in improving organizational performance through improvement activities and process re-engineering. Provides orientation to regulatory requirements and the LifeBridge Regulatory Readiness program for new leaders and staff members Supports and routinely presents at Regulatory Readiness & Accreditation Committee meetings and ad hoc workgroups created to address areas of non-compliance.

Compliance Monitoring: Serves as the subject matter expert for regulatory and/or accreditation standards.

Monitors compliance with regulatory standards and organizational policies and procedures by monitoring tracer completion, results, and data. Coordinates and conducts tracers to proactively assess compliance with regulatory standards and readiness for surveys. Completes periodic compliance review by evaluating tracer data and scoring the TJC standards & EPs in collaboration with the identified TJC Chapter Chairs. Works with senior leaders and the leadership team (directors and managers) to create interdisciplinary teams that meet routinely to proactively evaluate compliance, identify improvement tactics, and collaborate to achieve continuous readiness. Responsible for assessing the organization’s compliance status.

Data & Document Management: Maintain databases, documents, and sources of information for quality initiatives, accreditation efforts, and regulatory mandates.

Collects, analyzes, and tracks tracer and compliance data Serves as system administrator for tracer software system utilized by the hospital to monitor and track compliance with regulatory standards Maintains a system for organizing required documents Facilitates open and closed medical record review audits to assist in determining compliance with regulatory requirements and internal policies Disseminates the results of compliance audits/tracers and surveillance results as needed and as data is available. Tracks follow-up on identified non-compliance & support performance improvement efforts

Regulatory Improvement: Actively participates in the overall improvement and organizational performance.

Maintains effective communication with Hospital executives, leadership, physicians, and staff regarding departmental compliance monitoring activities and progress of performance improvement related to regulatory readiness. Identifies, plans for, communicates, monitors and evaluates actions to comply with existing and new regulations, standards and accreditation requirements. Provides consultative support in development and implementation of action plans. Assists in the development of actions plans with all levels of organizational leadership serving as a regulatory consultant and subject matter expert.

Education: Provides education to staff and physicians.

Educates staff on regulatory requirements, how to identify non-compliance, how to escalate concerns with non-compliance, and on problem-solving techniques for regaining and maintaining on-going compliance. Provides training and serves as a resource for compliance improvement, regulatory compliance orientation and continuing educational programs for providers, management, and staff. Develops educational tools and innovative ideas to promote learning regarding performance improvement, patient safety, and regulatory compliance.

QUALIFICATIONS AND REQUIREMENTS:

Seasoned professional knowledge; equivalent to a Master’s degree; knowledge in more than one discipline. Bachelor's degree is required; Organizational Development, Healthcare Administration or related healthcare field. 5-7 years of experience. Proficient to the point of being able to manage a database, create data reports, and interpret statistical reports. Frequently presents.

Additional Information

As one of the largest health care providers in Maryland, with 13,000 team members, We strive to CARE BRAVELY for over 1 million patients annually. LifeBridge Health includes Sinai Hospital of Baltimore, Northwest Hospital, Carroll Hospital, Levindale Hebrew Geriatric Center and Hospital and Grace Medical Center, as well as our Community Physician Enterprise, Center for Hope, Practice Dynamics, and business partners: LifeBridge Health & Fitness, ExpressCare and HomeCare of Maryland.