Accreditation and Regulatory Compliance Specialist (1.0 FTE, Days)
Company: Stanford Children's Health - Lucile Packard Childr
Location: Palo Alto
Posted on: May 16, 2022
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Job Description:
Here you have the potential and support to achieve extraordinary
outcomes for healthier, happy lives Accreditation and Regulatory
Compliance Specialist (1.0 FTE, Days) At Stanford Children's
Health, we know world-renowned care begins with world-class caring.
That's why we combine advanced technologies and breakthrough
discoveries with family-centered care. It's why we provide our
caregivers with continuing education and state-of-the-art
facilities, like the newly remodeled Lucile Packard Children's
Hospital Stanford. And it's why we need caring, committed people on
our team - like you. Join us on our mission to heal humanity, one
child and family at a time.
- Job Summary This paragraph summarizes the general nature, level
and purpose of the job. - In collaboration with the Director of
Accreditation, The Accreditation and Regulatory Compliance
Specialist manages all aspects of accreditation, regulatory and
hospital licensure compliance across the healthcare enterprise.
Provides consultation to healthcare enterprise leadership and
managers on accreditation readiness through participation in
operational committees, communication, facilitation and project
management. Communicates with involved organizational personnel
about accreditation/regulatory requirements, implications to the
healthcare environment and strategies to reliably achieve
compliance. Identifies opportunities for improvements based on
evidence based practices in regulatory and accreditation
compliance, analysis of internal and external compliance/risk
assessments and findings from regulatory authorities. -Essential
Functions The essential functions listed are typical examples of
work performed by positions in this job classification. They are
not designed to contain or be interpreted as a comprehensive
inventory of all duties, tasks, and responsibilities. Employees may
also perform other duties as assigned. Employees must abide by all
Joint Commission Requirements including but not limited to
sensitivity to cultural diversity, patient care, patient rights and
ethical treatment, safety and security of physical environments,
emergency management, teamwork, respect for others, participation
in ongoing education and training, communication and adherence to
safety and quality programs, sustaining compliance with National
Patient Safety Goals, and licensure and health screenings. Must
perform all duties and responsibilities in accordance with the
hospital's policies and procedures, including its Service Standards
and its Code of Conduct. Leverages experience in accreditation and
regulatory survey processes and builds upon current knowledge of
requirements related to CMS Conditions of Participation, The Joint
Commission, the California Department of Public Health and
California Children's Services (CCS). Interprets regulations,
licensure standards and accreditation standards, with an emphasis
on hospital, laboratory, and home care expectations. -
Develops and delivers education regarding internally and externally
driven trends in healthcare licensure, accreditation and regulatory
compliance. Assists managers and staff with workflow development,
policy and procedure review/revision, mock survey assessments, and
ongoing education
Leads accreditation/regulatory efforts involving LPCH leaders and
departments to assess policies, evaluate workflows, observe
clinical care, interview team embers, assess environment of care,
etc. with goal of identifying gaps, consulting on priority of items
needing correction, researching and advising on reliable compliance
strategies utilizing evidence-based practice. Helps to create
reliable quality assurance processes to monitor success of
corrective action plans
Assists Directors of Accreditation and Regulatory Compliance,
Quality Management, Patient Safety and Professional Practice
Evaluation, and Infection Prevention and Control in facilitating an
integrated organizational approach to assessing and meeting
regulatory requirements and process improvements
Partners with operational leaders and relevant support departments
e.g. Patient Safety, Infection Control, to develop corrective
action plans and to track the success of corrective actions
Consistently aligns priorities of accreditation and regulatory
compliance efforts with hospital's culture of safety and PCARES
programs. Supports efforts to ensure compliance to the National
Patient Safety Goals
Partners with Directors of Accreditation and Regulatory Compliance
and Patient Safety to reliably identify and report applicable
safety incidents to CDPH in a timely manner. Participates in and
supports the evaluation of CDPH entity-reported incidents and
complaints as needed
Gathers and submits necessary documents to support maintenance of,
and changes to, hospital's CDPH licensure. Supports operational
leadership and laboratory department leadership to track status of
laboratory licenses/CLIA certificates, identify compliance
opportunities, and to implement of corrective actions
Helps to provide direction to Accreditation and Regulatory
Compliance Department Coordinator in collection of required CCS
certification materials and participates in onsite CCS surveys, as
needed
Assists Director with coordination of regulatory surveys by Joint
Commission, CMS, CDPH and CCS. Supports department-specific surveys
by regulatory and accreditation authorities such as FDA, DEA, CAP,
CMS Transplant, CMS End Stage Renal Disease, etc., as needed
-Minimum Qualifications Any combination of education and experience
that would likely provide the required knowledge, skills and
abilities as well as possession of any required licenses or
certifications is qualifying.
Knowledge of project management and change management methodologies
and tools
Knowledge of and ability to apply performance improvement
methodologies and tools to projects (e.g., A3 thinking, PDCA, value
stream and process mapping, root cause analysis, etc.)
Knowledge of computer systems and software used in functional
area
Knowledge and proficiency in the use of Microsoft Office Suite of
applications and clinical documentation systems (preferably
EPIC)
Ability to communicate effectively to facilitate positive working
relationships and achieve desired outcomes
Ability to lead interdisciplinary groups to review high-risk
workflows, identify compliance gaps, and facilitate development and
reliable implementation of solutions
Excellent interpersonal skills and is talented at leading the
efforts of multidisciplinary team initiatives. Physical
Requirements The Physical Requirements and Working Conditions in
which the job is typically performed are available from the
Occupational Health Department. Reasonable accommodations will be
made to enable individuals with disabilities to perform the
essential functions of the job Equal Opportunity Employer L ucile
Packard Children's Hospital Stanford strongly values diversity and
is committed to equal opportunity and non-discrimination in all of
its policies and practices, including the area of employment.
Accordingly, LPCH does not discriminate against any person on the
basis of race, color, sex, sexual orientation or gender identity,
religion, age, national or ethnic origin, political beliefs,
marital status, medical condition, genetic information, veteran
status, or disability, or the perception of any of the above.
People of all genders, members of all racial and ethnic groups,
people with disabilities, and veterans are encouraged to apply.
Qualified applicants with criminal convictions will be considered
after an individualized assessment of the conviction and the job
requirements, and where applicable, in compliance with the San
Francisco Fair Chance Ordinance.
Keywords: Stanford Children's Health - Lucile Packard Childr, Palo Alto , Accreditation and Regulatory Compliance Specialist (1.0 FTE, Days), Other , Palo Alto, California
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