Quality Regulatory & Accreditation Specialist

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Day - 08 Hour (United States of America) This is a Stanford Health Care Tri-Valley job.

The Quality Regulatory & Accreditation Specialist is responsible for planning, coordinating, monitoring, and improving the accreditation, regulatory, & licensure compliance of clinical care and services at the hospital. This position is responsible for leading multiple small to medium scale, service or unit specific, performance improvement initiatives. This role combines the acumen required to change practice with the leadership skills to influence clinical processes, systems, and outcomes.

This position will assess and develop ongoing compliance strategies within the system of care. The Quality Regulatory & Accreditation Specialist identifies opportunities for unit/service-based improvements based on evidence-based practices, regulatory and accrediting agency requirements, and data analysis of high risk, high volume and/or problem prone processes. This position is responsible for negotiating timelines and priorities for projects, coordinating action plans, and monitoring/analyzing results for projects that are consistent with the unit/service strategic goals which should be aligned with the organizational quality imperatives.

Stanford Health Care Tri-Valley.

Co-facilitates local, state, and federal clinical regulatory and accreditation activities for Stanford Health Care Tri-Valley to ensure that clinical services are provided in accordance with established standards. Performs, coordinates, and co-facilitates ongoing accreditation and regulatory readiness and quality improvement initiatives for assigned projects to achieve unit/service goals, working collaboratively with leaders, physicians, and staff of designated unit/service. Responds to on-site surveyors and regulatory agencies related to patient care matters.

Meets surveyor when they arrive on site. Function as a host and/or escort to accreditation and regulatory surveyors who come onsite to conduct compliance assessment and investigation. This role may also be involved co-managing a survey command center and developing and managing plans of corrections. Notifies appropriate departments that their area may be visited when the regulatory or accreditation surveyors arrive and is responding to a patient care complaint, never-event notification, or survey.

Working with ACNO Patient Safety, Accreditation, and Nursing Excellence to submit reports to agencies as indicated after serious adverse event or unusual occurrence. Performs data analysis; creates & interprets data displays. Works collaboratively with Clinical and Support Services, senior and middle management, Compliance, Office of General Counsel, Risk Management, Information Technology, and others to ensure the integrity and accuracy of the data that is utilized.

Utilizes Microsoft programs, RLDatix, applicable Joint Commission web-based applications, online survey/assessment tools, and other applications & databases. Evaluates data, makes judgments, and recommendations regarding accreditation and regulatory work, including but not limited to results from mock and real surveys, assessments, and information from internal/external consultants, as well as accreditation and/or regulatory reviewers. Designs and develops dashboards and other innovative data visualization using business intelligence tools.

Provides content knowledge in the interpretation, implementation, and maintenance of standards to match external requirements (e.g., Joint Commission, CMS Conditions of…