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The Accreditation Specialist is responsible for the preparation and coordination of efforts related to Center for Medicare and Medicaid Services (CMS), The Joint Commission (TJC), Ohio Department of Health (ODH) and other regulatory body compliance; and maintaining a constant state of service readiness for The Christ Hospital Health Network. This includes maintaining knowledge of all standards, updates to standards and tracking compliance within accreditation database.

Compliance:

• Coordinates interpretation and evaluation of compliance with The Joint Commission, ODH, and CMS standards.
• Coordinates interpretation and evaluation of compliance with other regulatory bodies, including but including OSHA, Ohio Department of Mental Health and Addiction Services, FDA, EPA, etc.
• In collaboration with the Manager of Quality Programs the Accreditation Specialist chairs regulatory committee and provides direction for assigned TJC chapter and standard leads.
• Assists in performing gap analysis of current state of compliance and formulating action plans, responsibilities, and completion dates to bring organization into compliance.
• Maintains a working knowledge and understanding of the intent of standards, regulations, and agency scoring.
• Reviews official TJC publications and provides summary to department manager and director monthly.
• Serves as an expert resource for the intent of the standards and communicates to appropriate personnel, organizational management, and physicians.
• Collaborates and serves as a resource for hospital departments for standards set forth by accrediting and regulatory agencies.
• Assists departments in assessing, planning, implementing, and monitoring activities to assure compliance.
• Assures adequate and appropriate education and communication relative to standards set by accrediting and regulatory agencies.
• Attends local and regional workshops to stay abreast of changes or revisions in standards and regulations.
• Assists in review and evaluation of departmental and organizational programs and policies to ensure that they guide reimbursement, comply with the standards and regulations set forth by TJC and other regulatory agencies.
• Conducts patient tracers to determine current state of readiness to ensure that the hospital staff is prepared for the accreditation process.
• Mechanisms are developed and maintained to ensure that frontline management is aware of the status of departments in regard to compliance.
• Implements efforts so that the organization is in a constant state of survey readiness.
• Checks TJC Extranet site every morning for survey postings, email communication, new complaints or sentinel event requests for information and communicates to department leadership.
• Maintains and organizes all critical documentation support in compliance with requirements to include the development of delivery and follow-up documentation (i.e., reports, plans, appeals, etc.).
• Coordinates mock and "on-site" unannounced Joint Commission survey.

Data Management:

• Coordinates data management related to tracking regulatory compliance. Provides routine reports to hospital leadership relative to standards of compliance.
• Is an expert user for AMP Software system and assists Chapter leads with the scoring and evidence documentation in the system.
• Maintain ongoing documentation and database related to our required annual Periodic Performance Review. Communicates non-compliance standards, action plans, and measures of success to department leadership.
• Assists in providing instruction and training to other system users.
• Assists in creation of reports related to tracking compliance

Project Management:

• Promotes a positive working relationship between management, staff, and other departments through effective communication and interpersonal skills.
• Effectively integrates change management theory into communication and training activities.
• Management is kept informed of the status of activities, problems, and new initiatives.
• Serve as primary contact point to stakeholders to implement action plans for deficiencies identified during internal audits and external surveys.
• Ensure timely progress toward compliance to standards and escalation of barriers as appropriate.

Education:

• Assists in coordination of training and communication related to regulatory compliance.
• Develops, coordinates, and implements both individual and group structured programs in response to learning needs.
• Principles of adult education and learning theories applied when developing teaching plans and when implementing the instructional process.
• Assists in the development of content of annually required safety and regulatory information.

Professional Development:

• Participates in professional organizations relating to quality improvement and regulatory compliance.
• Actively promotes a positive image of The Christ Hospital with the public and professional community.
• Demonstrates a coaching approach in developing the skills and potential of all professional staff and promotes a sense of empowerment in performance of their duties.
• Supports all hospital policies/procedures.

Performs other duties as assigned.

KNOWLEDGE AND SKILLS:

EDUCATION: Bachelor's Degree in a health-related field, health care management, or business management required, master's degree preferred. Graduate Registered nurse from an accredited College of Nursing with BSN Degree preferred.

YEARS OF EXPERIENCE: A minimum of three (2) years of accreditation or health care management related experience or 3-5 years of acute care nursing or related health care experience is required.

REQUIRED SKILLS AND KNOWLEDGE:

• Current knowledge and understanding of regulatory and accreditation agency standards, preferred.
• Ability to work with a variety of disciplines and levels of staff across departments and the organization.
• Effective presentation, written and oral communication skills.
• Effective problem-solving and time management skills.
• Knowledge of evidence-based practice and principals.
• Knowledge and application of a wide variety of advanced performance improvement tools and methods.
• Ability to manage multiple projects.
• Knowledge and training in multiple computer systems required to perform position responsibility such as: Microsoft office, Power point, Excel, Outlook required; EPIC and MIDAS experience preferred.

LICENSES REGISTRATIONS &/or CERTIFICATIONS :

Preferred: Certification in Healthcare Quality (CPHQ), RN License in the State of Ohio