Regulatory​/Accreditation Consultant - 136100

Regulatory/Accreditation Consultant

Peace Health is seeking a Regulatory/Accreditation Consultant for a Full Time, 1.00 FTE, Day position. The salary range for this job opening at Peace Health is $46.27 – $69.41. The hiring rate is dependent upon several factors, including but not limited to education, training, work experience, terms of any applicable collective bargaining agreement, seniority, etc.

Job Summary

Supports coordination and facilitation of accreditation and regulatory work for hospitals within assigned networks. Accountable for accreditation regulatory program with assigned scope of responsibility to include, but not limited to identifying gaps in compliance with state hospital licensing and accreditation standards, communicating to leadership on high-risk compliance issues, and supporting the development of local leaders and staff to be aware of rules pertaining to their areas of responsibility relating to regulatory compliance.

Works with other disciplines and regulatory departments to coordinate compliance efforts across the Peace Health system. Serves the organization to promote operational standardization by maintaining one interpretation throughout Peace Health as it applies to rules and regulations monitored by this department.

Essential Functions

• Leads regulatory survey readiness program planning to support Peace Health's mission, vision and values as related to regulatory compliance.
• Works with regulatory team, local leadership, stakeholders, and subject matter experts to provide oversight to ongoing regulatory readiness within the networks Conducts tracers, internal audits and rounding activities to identify vulnerabilities and to validate compliance with accreditation and regulatory standards. Communicates information and report(s) to appropriate managers, committee, and leadership.
• Proactively addresses accreditation and regulatory compliance issues; works with other departments/system staff to assign ownership and works to correct identified issues prior to external regulatory review.
• Supports post survey activities, which include creation and continued monitoring of corrective action plan activity.
• Maintains required reports and summaries of noncompliant issues and survey activity in appropriate databases and updates as needed. Utilizes information to prioritize and provide regulatory reports to facilities as scheduled.
• Provides on-site accreditation survey support. Works with system and local regulatory team to assure the Survey Command Center is always ready to support survey processes. Serves a key support in the Command Center during survey. Assists in education and training of local leaders regarding command center functions. Documents and processes with facility management and leaders. Reviews survey materials at least quarterly and education at least biannually to ensure strong coordination and staff knowledge of role during external surveys.
• Assists with the development and implementation of regulatory education and core educational materials for leaders and caregivers. Provides local regulatory expertise to promote operational compliance using standard tools and approaches, consistent interpretation of rules and regulations, standardization of process/practice, and outcomes management.
• Participates and assists with the creation of standard work processes pertaining to department; educates and orients local leaders to standard work processes.
• Participates on system and/or local teams charged with regulatory improvement work as needed.
• Serves as the liaison between assigned accreditation/ regulatory bodies and the hospital.
• Works with local leadership, stakeholders and subject matter experts to provide oversight to ongoing regulatory readiness within the networks Conducts tracers, internal audits and rounding activities to identify vulnerabilities and to validate compliance with accreditation and regulatory standards. Communicates information and report(s) to appropriate managers, committee and leadership. Creates tools for manager to utilize to maintain compliance in their designated units.
• Proactively addresses accreditation and regulatory compliance issues; works…