Senior Accreditation Regulatory and Licensing Specialist
Full Time
Pleasanton, CA 94588
$59.90 - $76.56 an hour
Posted
Job description
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Day - 08 Hour (United States of America)
Job Summary
The Senior Quality Consultant is the advanced level of professional work involving the performance of a broad range of professional administrative, analytical, and consultative duties related to assessing, planning, implementing, coordinating, monitoring, and evaluating accreditation, regulatory & licensure compliance strategies of Stanford Health Care ValleyCare. In collaboration with senior leadership, physicians, and multi-disciplinary health care providers, the Senior Quality Consultant identifies, conducts and manages complex analytical projects, plans and executes strategies, plans initiatives and methods that provide a comprehensive approach to promoting a strong patient safety culture and clinical effectiveness through effective identification and analysis of safety data and quality indicators, proactive risk assessment, refinement/redesigning of systems and processes, interventions, staff training and patient and family engagement. 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 Senior Quality Consultant identifies opportunities for unit/organizational/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/organizational/service strategic goals which should be aligned with the organizational quality imperatives.
Essential Functions
The essential functions listed below are general examples and not a description of comprehensive duties. Specific duties and responsibilities may vary depending on department or program needs without changing nature or scope of this position or level of responsibility. May be asked to perform other duties as assigned.
- Facilitates local, state, and federal clinical regulatory and accreditation activities for Stanford Health Care - ValleyCare to ensure that clinical services are provided in accordance with established standards.
- Responds to on-site surveyors and regulatory agencies related to patient care matters. Meets surveyor when they arrive on site and coordinates all visit activities. The Senior Quality Consultant will be responsible for managing a survey command center.
- 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.
- Establishes processes to ensure that comprehensive reviews of events are timely and that information is sufficient for hospital leadership to make determinations regarding regulatory reporting.
- Collaborates with department managers, physicians, and staff to continuously improve operations, increase performance and streamline processes for continuous readiness.
- Keeps meticulous records of the visit including documents reviewed, data, minutes, interviews, and other requests for information.
- Advises staff, managers, and physicians during the regulatory or accreditation visits on how to respond to surveyors and requests for information.
- Coordinates post visit responses to findings and deficiencies to ensure that action plans are in place to bring the organization back into full compliance within the established timeline.
- Collaborates regularly with risk management, quality, compliance, and operational managers/directors to continually improve our regulatory accreditation compliance, patient safety, and outcomes of care.
- Prepares responses to survey/visit findings, monitors action plans, and reviews results.
- Researches proposed and new regulatory and accreditation requirements related to patient care and translates relevant issues to leadership, existing task forces, quality improvement teams, committees, management and others in the development, revision, and review of policies, processes, and services to ensure ongoing compliance with standards.
- Develops and maintains relationships and effective communication with all levels of the medical staff, managers, and staff in order to facilitate problem identification and resolution; models exemplary customer service standards.
- Develops and implements the organization’s continuous survey readiness program.
- Performs data analysis; creates & interprets data displays, including clinical, cost, and patient satisfaction data. 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 Participation, California Title 22 and Health and Safety Codes, National Fire Protection Agency)
- Prepare and maintain documentation for continuous California Department of Public health hospital licensure and notification requirements.
- Assist with the development and revision of the hospital’s policy manual and functions as a consultant to the organization on policy management.
- Employee must perform all duties and responsibilities in accordance with the C-I-CARE Standards of the Hospital. C-I-CARE is the foundation of Stanford Healthcare – ValleyCare’s patient-experience and represents a framework for patient-centered interactions
Job Qualifications
Education
- Bachelor’s Degree with eight (8) years of healthcare experience or Master’s degree with five (5) years of health care experience from an accredited college or university.
Experience
- Eight (8) years of progressively responsible and directly related work experience, five (5) years with a Master’s, within a large acute care hospital of health care system in one or more of the following areas:
- data based performance improvement, including patient safety
- quality assurance/quality improvement
- regulatory, accreditation and licensing
- clinical experience, such as nursing or pharmacy.
- Four (4) years of accreditation, regulatory & licensure experience in California preferred. Experience with successfully preparing and completing CDPH licensing for hospital and clinic space and facilitating successful CDPH licensing surveys and complaint investigations.
Licenses and Certifications
- CPHQ, CPHRM, or CJCP certification is preferred.
Knowledge, Skills, and Abilities
- Ability to utilize the quality improvement framework to ensure that performance improvement initiatives focus on improving outcomes, appropriateness of care, patient centeredness, and value.
- Ability to coordinate project initiatives, meetings, and clinical program management to achieve service and unit specific goals and strategic direction.
- Knowledge of change management tools/techniques and is able to apply them to projects.
- Knowledge of and ability to apply performance improvement methodologies and tools to projects (e.g. Lean, Six Sigma, proactive risk assessments, and Root Cause Analysis).
- Knowledge of quantitative skills and ability to use statistics to evaluate and interpret data, summarize results and make recommendations.
- Knowledge of project management and change management methodologies and tools.
- Ability to understand and use structure to drive process changes and how to use processes to drive towards desired outcomes.
- Ability to work collaboratively in a multi-disciplinary environment.
- Ability to demonstrate sound judgment, reasoning, and detail oriented.
- Ability to understand and use information technology to drive process changes.
- Ability to influence effectively to create synergy, prioritize projects, set goals and actions plans, and measure impact.
- Knowledge of and ability to stay abreast with California Title 22 and Health and Safety Code regulations, Joint Commission Hospital and Laboratory accreditation standards, Joint Commission’s Disease –specific Care Certification, and Medicare CMS Conditions of Participation (specifically Appendix A).
- Ability to stay abreast with relevant National Fire Protection Agency (NFPA) codes as they pertain to the hospital’s Joint Commission’s accredited space.
- Expert proficiency with web-based tools, including Survey monkey, and Joint Commission’s e-Application.
Physical Demand and Working Conditions
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
Equal Opportunity Employer Stanford Health Care - ValleyCare (SHC - VC) 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, SHC does not discriminate against any person on the basis of race, color, sex, sexual orientation or gender identity and/or expression, 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.
Equal Opportunity Employer Stanford Health Care (SHC) 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, SHC does not discriminate against any person on the basis of race, color, sex, sexual orientation or gender identity and/or expression, 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.
Base Pay Scale: Generally starting at $59.90 - $76.56 per hour
The salary of the finalist selected for this role will be set based on a variety of factors, including but not limited to, internal equity, experience, education, specialty and training. This pay scale is not a promise of a particular wage.
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