Plans, coordinates, implements, and evaluates enterprise, facility, and programmatic regulatory programs for preparedness and accreditation/certification/licensure requirements. Acts as the organizational subject matter expert to leadership, staff, and system teams/work groups as related to regulatory requirements to ensure standards are met. Continuous Joint Commission Survey readiness is a priority. Focuses on facilitating compliance with accreditation standards, the Centers for Medicare and Medicaid Services (CMS) conditions of participation, and the Arizona Department of Health Services (ADHS) regulations, as well as managing the Document Control system. Acts as a leader of the center of excellence designation, ongoing compliance, certifications, and other related activities.as directed. Serves as a subject matter expert on internal and external regulatory standards. Provides education to address regulatory changes and gaps in regulatory compliance. Guides leaders and staff to ensure they understand regulatory requirements. Serves on assigned committees, as chair or co-chair, as appointed. Schedules and maintains regulatory meetings, updating the committees on current and planned procedures, capabilities, and actions.

Regulatory and Accreditation:
*Implements regulatory requirements through standardized processes across one or more facilities or entities and prepares these facilities for surveys by assessing infection prevention and control measures, as well as the Environment of Care (EOC) and Life Safety Code (LSC) compliance.

*Reviews, evaluates, and assists in the development and implementation of facility policies, procedures, and guidelines to ensure regulatory compliance, including making recommendations on all matters related to compliance with the Joint Commission, CMS, and national, state, or local regulations as well as professional standards.

*Develops and leads Joint Commission and ADHS continuous readiness initiatives across the system to assure continuous regulatory survey compliance.

*Develops and maintains the TJC Tracer Program (Illuminate), including but not limited to: development and testing of tracer tools, training and education of new and existing users, adding new users, creating tracers as requested, facilitating monthly report creation and distribution.

*Develops analytical tools to facilitate the identification of opportunities for improvement based upon tracer findings.

*Leads interdisciplinary regulatory readiness and ad-hoc action planning teams for specialized certification programs (e.g., Trauma, Stroke).

*Participates in proactive rounding, conducts observations, tracers, building tours, document reviews, and interviews to ascertain facility compliance with standards, rules, and regulations. Documents findings and provides the facility with reports and recommendations for change.

*Supports and facilitates the development of Evidence of Standards Compliance action plans generated from TJC survey findings based upon process improvement methodology.

*Responds to notices of surveyor arrival at facilities by directing survey management activities, clarification of standards, support, and assistance to the senior leadership team. Initiates and directs post-survey activities to ensure the facility meets regulatory process requirements. Schedules and participates in the unannounced corporate surveys system-wide. Identifies and coordinates compliance activities of regulatory content experts such as infection control and EOC/LS specialists.

*Supports internal and consultant-driven mock survey activities.

Quality Review and Accountability & Health Data Analytics
*Lead compliance initiatives with voluntary, mandatory, and contractual reporting requirements for data acquisition, analysis, reporting, and improvement.

*Acquire data from source systems.

*Design/develop data collection plans for key performance indicators.

*Select and utilize appropriate statistical tools and visualization methods to transform data into Information.

Performance and Process Improvement
*Evaluate and utilize process improvement methods (e.g. LSS, PDSA) best suited to achieving successful outcomes.

*Access and use information resources (Regulatory standards, Electronic Health Records, registries, databases, comparative and benchmark data, and published research) to demonstrate current practice, identify opportunities for improvement, and strive toward improved outcomes.

*Lead action-oriented teams utilizing change management principles and tools.

*Provides direction and education to facility functional team leads on completion of the Periodic Performance Review, standardized metrics, and action plans for resolution of identified non-compliance with regulations and standards. Supports development and monitors completion of facility plans of correction. Oversees and assists functional teams and department managers in the development of corrective actions.

Document Control and Management
*Leads Document Control Committee.

*Oversees the maintenance and management of the Document Control System.

*Leads organizational initiatives to streamline the document control process, minimizing extraneous documents and facilitates ease of use.

*Implement workflows that ensure that information-related policies align with the most recent regulations.

*Develops reports for tracking and trending of overdue documents, document reviewer and ownership accuracy.

*Develop education for system users, document owners, and those who approve documents.

*Collaborate with leaders across the organization to ensure that users receive appropriate training on use of the system.

Patient Safely
*Assess the organization's patient safety culture and work with leaders on identifying behaviors that impact safety culture.

*Apply safety science principles and methods to identify root causes and potential solutions when safety risks are discovered.

*Identify and report any safety-related incidents in a timely fashion through the Vigilanz Safety Event Reporting System; attend all safety-related training programs; safely perform work; monitor the care environment for possible safety Issues and ensure others are also safely performing work.

Professional Engagement
*Integrate ethical standards into healthcare quality practice.

*Engage In lifelong learning as a healthcare quality professional.

*Participate in activities that advance the healthcare quality profession.

Compliance and Safety
* Responsible for reporting any safety-related incident in a timely fashion, attends all safety-related training programs, performs work in a safe manner, monitors work environment for possible safety issues and ensures others are also performing work in a safe manner.

* Stays current and complies with state and federal regulations/statutes and company policies that impact the employee’s areas of responsibility.

* If required for the position, ensures all certifications and/or licenses are up-to-date and valid prior to expiration dates.

* Completes all company mandatory modules and required job-specific training in the specified time frame.

Education
Bachelor's degree in a related field - Required

Certification & Licensures
Process Improvement Experience and/or Training (LSS Green Belt ) - Preferred
Certified Professional ln Healthcare Quality (CPHQ) - Preferred
Healthcare Accreditation Certified Professional (HACP) - Preferred
Certified Joint Commission Professional (CJCP) - Preferred

Experience
5 years of experience in regulatory readiness, accreditation, compliance or healthcare quality. - Required
Exceptional written and verbal communication skills - Required
Strong interpersonal and relationship building skills - Required
Experience manipulating data and creating tables in Excel - Required
Experience supporting organizational accreditation (e.g. Joint Commission, DNV, CMS)- Preferred
Experience using Total Quality Management (TQM)/ Continuous Quality Improvement (CQI) - Preferred
Healthcare is a rapidly changing environment and technology is integrated into almost all aspects of patient care. Computers and other electronic devices are utilized across the organization and throughout each department. Colleagues must have an understanding of computers, and competence in using computers and basic software programs.