Accreditation and Regulatory Specialist (Nurse)

Position Summary

Under the direction of the Senior Director, Accreditation & Regulatory and working collaboratively, the Accreditation and Regulatory Specialist (Nurse) leads efforts to ensure continual organizational compliance and ongoing readiness with clinical quality and patient safety standards and regulations required by The Joint Commission, Massachusetts Department of Public Health and Center for Medicare and Medicaid Services.

In this role the Specialist proactively plans, implements, coordinates and continually improves the Boston Medical Center’s (BMC) efforts related to compliance, accreditation and licensure requirements.

Position : Accreditation and Regulatory Specialist (Nurse)

Department : Regulatory Compliance

Schedule : Full Time

Essential Responsibilities / Duties

Provides support and content knowledge for The Joint Commission, DPH and CMS standards, regulations and conditions of participation.

Responsible for assisting in the interpretation of regulatory and licensing requirements throughout the organization.

Provides education and consultation to administrative and clinical leadership, staff and faculty throughout BMC regarding the requirements of accreditation and regulatory organizations, using both formal and informal venues, e.

g. presentations, publications, email, computer-based methods.

Provides guidance and assistance to departments, sections, units and programs regarding improvements needed to ensure compliance with requirements of TJC, DPH and CMS.

Provides consultation to assist administrative and clinical leaders and their departments in improving performance.

Builds effective, supportive, productive relationships with leadership, staff and faculty throughout BMC.

Facilitates and supports the development of tools, policies, and procedures, and learning aids to promote compliance with standards.

Provides new and revised TJC, CMS, DPH standards and interpretations to administrative and clinical leadership, staff and faculty.

Works closely and supports the Senior Director in building effective working relationships with accreditation and regulatory agencies, i.

e., The Joint Commission, DPH and CMS.

Requirements

Responsible for all aspects of the plan to ensure continual readiness with the clinical regulatory and accreditation requirements of the TJC, DPH and CMS.

This includes but is not limited to :

• Development, coordination, and implementation of the continual readiness plan
• Ongoing assessment of the continual readiness plan; identification of needed improvements; and preparation and implementation of plans to achieve needed improvements
• Organizational, department, section, unit and program assessments and identification of risk
• Plan and scheduling readiness mock surveys
• Completion of annual TJC application
• Periodic Performance Review completion and submission
• Development of remedial action plans
• Supporting the Senior Director on agency requests for revision and corrective action plans

Responsible for communication of the continuous readiness plan to Senior Director and key groups throughout BMC.

Responsible for ensuring preparation of reports assessing institutional, department, section, program and unit compliance with accreditation and regulatory requirements.

Ensure that administrative and clinical leadership are continuously aware of BMC readiness for TJC, DPH and CMS surveys, including description of specific issues that are in need of improvement.

Works closely with Risk Management, Quality Improvement & Patient Safety and Clinical Analytics including coordination of the Joint Commission Performance Improvement and NPSG standards compliance.

Leads a coordinated response to unannounced external accrediting or regulatory agency visits such as DPH, Joint Commission or CMS.

Co-chairs TJC Steering Committee.

Responsible for overseeing the BMC policy and procedure system including supporting the chair of the Policy and Procedure Roundtable.

Works with Risk Management on an as-need basis to support BORM and DPH requirements regarding reporting of adverse events and onsite surveys.

Other duties as directed, including the occasional work with non-clinical regulatory agencies such as OSHA.

Education

JOB REQUIREMENTS

Baccalaureate Degree in Nursing required; Master in Healthcare related field preferred

Certificates, Licenses, Registrations Required

Certification in Accreditation preferred

Experience

2 years of experience with The Joint Commission, DPH and other regulatory requirements and survey processes.

Knowledge And Skills

• Outstanding team player.
• Ability to develop effective relationships with a broad array of people from diverse backgrounds.
• Strong interpersonal skills; ability to establish supportive, collegial relationships.
• Superior organizational skills to manage a large volume of incoming data, information, reports, etc. in paper and electronic formats.
• Ability to create and deliver appealing and compelling presentations to a variety of audiences including clinicians, staff, faculty, administration and governance groups.
• Excellent written and verbal communication skills.
• Demonstrated skill in change management and quality improvement.
• Knowledge of clinical terminology.
• Strong computer skills including Microsoft Office platform Word, Access, Excel, E-mail. Web / Internet.
• Ability to learn and effectively use computer software, such as electronic health records and data entry.

Equal Opportunity Employer / Disabled / Veterans