The Regulatory Coordinator is a leader with enterprise wide responsibility related to maintaining a continuous level of preparation for all announced and unannounced surveys. This position utilizes high reliability principles to evaluate and address adherence to state licensing laws, CMS Conditions of Participation, Joint Commission standards or other deeming agencies.
- Family-Centered care that focuses on the need of the child first and values the family as an important member of the care team
- Excellence in clinical care, service and communication
- Collaborative within our institution and with others who share our mission and goals
- Leadership that set the standard for pediatric health care today and innovations of the future
- Accountability to our patients, community and each other for providing the best in the most cost-effective way.
Regulatory and Accreditation Expertise
- Serves as primary subject matter expert for Accreditation standards (Joint Commission), CMS conditions of participation and State licensing regulations. Primary responsibility for survey process, survey process changes, and compliance results, new and changes standards.
- Leads all internal efforts to assess, improve and proactively prepare the organization for unannounced surveys with development of effective action plans to improve performance.
System Assessment aligned with Safety and Outcomes
- Develops and manages a comprehensive system for assessing organizational compliance and risk based upon outcomes, concurrent observation of practices, tracer findings, mock survey findings, and actual survey findings and other methods.
- Performs risk assessments in a variety of settings and creates improvement plans by prioritization of risk factors. Develops effective improvement plans with leadership involvement.
- Provides updates on progress for organizational improvements, aligns resources and communicates this information to the appropriate personnel.
Infrastructure development including policies, procedures and operational standardization.
- Develops and manages an effective organization wide assessment comparing regulations to practice. Identifies gaps and works with local area management for improvement. Manages internal system for continual preparation including education and practice operation review related to all relevant survey regulations and standards.
- Serves as a subject matter expert related to policies and procedures, which will support operations and compliance with regulatory/ accrediting agencies.
Subject Matter Expert for Healthcare Environment and Safety Methodology
- Serves as a subject matter expert as related to internal quality and performance standards. Familiarity with improvement science methodology using tools and methods as it relates to regulatory/accreditation risk points and improvement work.
- Supports facility leadership to identify areas for improvement and educates practices on tools and methods as needed.
- Participates in formal improvement teams as needed related to regulatory and accreditation issues.
- Identifies learning needs and actively drives personal improvement. Is able to assess skill level related to improvement activity, organizational change and other regulatory related issues. Participates in professional organizations and national/state education programs and applies learning to improve organization and personal performance.
- Performs miscellaneous job related duties as requested.