System Regulatory Specialist - Clinical Outcomes and Resource Management

The regulatory specialist supervises all aspects of and provides strategic support for the organization by providing expertise in continual survey readiness and associated regulatory concepts.

The regulatory specialist acts as a role model and resource to the healthcare team by enhancing safety and quality care.

The regulatory specialist assists the team to understand and incorporate best practices to promote excellent patient outcomes and continual readiness.

Office will be located at The Toledo Hospital, but the position will require travel to all ProMedica Hospital locations.

ACCOUNTABILITIES

All duties listed below are essential unless noted otherwise*

1. Maintains current knowledge of regulatory standards and survey processes for all regulatory bodies who oversee deemed status and specialty designations (, CMS, TJC, ACHC, OSHA, ODH, MDHHS, etc.).

2. Informs senior leadership of current and potential regulatory / continual readiness issues at site- and system-levels.

Serves as a resource and mentor to senior leadership on regulatory topic interpretations.

3. Initiates, conducts, analyses, and reports on process improvement efforts by utilizing tools including, but not limited to audits, FSAs, rounds, PDSAs, gap analyses, FMEAs, and tracers to guide organization in assuring system-level continual readiness.

4. Guides all levels within the organization in preparation for surveys, site visits, and regulatory reviews; manages survey processes to assure compliance during review with organizational policy and associated regulations;

guides creation of and monitors ongoing adherence with process improvement secondary to survey findings.

5. Assists in the creation of education for all levels of leadership as required to maintain a culture of continual readiness.

6. Collaborates with and guides Chapter Chairs, senior and frontline leadership to identify patient safety and regulatory concerns, and initiates action plans with a system-level approach whenever appropriate to opportunities identified.

7. Attends and / or manages meetings to disseminate regulatory information and findings on a routine and as-needed basis across the organization.

8. Investigates payer and regulatory quality of care concerns and guides action plan creation and written responses in collaboration with affected leadership.

• 9. Assists in the creation and maintenance of regulatorily required documents, including but not limited to policies; guidelines;
• scopes of service; statement of deficiency forms; other written regulatory responses; required survey documents; deemed status application updates;

hospital licensure letters; etc.

10. Supports organizational initiatives around clinical specialty certification and serves as a consultant for excellence in patient care.

11. Other duties as assigned.

Job Requirements

Education : BSN

Skills : Requires excellent critical thinking and analytical skills. Should be able to enter data into a database, input and retrieve information from a computer.

Must be able to communicate well with all levels of employees and to organize and implement educational activities. Must be able to understand directions, communicate and respond to inquiries in a fast-paced environment.

Requires effective interpersonal skills. Must be able to effectively construct and manage multiple process improvement projects simultaneously.

Years of Experience : 2+ years Nursing

License : RN State of Ohio or Michigan

PREFERRED QUALIFICATIONS

Education : MSN Preferred

Skills : Collaborative, process improvement experience.

Years of Experience : 4+ years Nursing

Certification : CHPQ

WORKING CONDITIONS

Physical Demands : Must be able to move about hospital and between workstations; and prolonged periods of standing. Must be able to frequently move, life or carry materials.

The above list of accountabilities is intended to describe the general nature and level of work performed by the

positions; it should not be considered exhaustive.