Primary City/State:Four Peaks Medical Center - 1301 S Crismon Rd Mesa, AZ 85209
Category:Operations
Shift:Day
Department:Quality Improvement Division
Full Time, Mon-Fri
Responsibilities:Job SummaryProvides operational support and management for federal certification, state licensure, and accreditation compliance programs within HonorHealth. Under direction of AVP Regulatory/Accreditation, develops, implements, manages and maintains comprehensive programs and projects and provides consultation, education and teaching to leadership, medical staff, and external customers to strengthen network performance in regulatory/accreditation compliance. Initiates/leads necessary improvements to ensure continual compliance with applicable regulatory and accreditation standards. Works closely with Nursing and Patient Safety Program on performance improvement activities leading to continual performance improvement.
Essential Functions- Ensures continual network-wide compliance with federal certification and state licensing regulations and accrediting body standards. Serves as the entry-point for regulatory/accreditation issues in maintaining network outpatient center compliance. Leads clinical regulatory and accreditation compliance teams. Coordinates the preparation for regulatory and accreditation surveys to maintain HonorHealth in a state of continual readiness for scheduled and unannounced surveys. Serves as the clinical compliance expert during on-site surveys.
- Assesses current clinical and non-clinical performance and identifies potential or actual patient safety issues. Coordinates corrective and preventive action when opportunities for improvement are identified. Works in a collaborative manner with facility staff as well as associated Quality staff for improvement. Responds effectively to regulatory and accreditation deficiencies. Assures reporting deadlines are met and data reported are consistent with current requirements to maintain good standing with accrediting/regulatory agencies.
- Leads clinical quality and continuous improvement teams related to corrective action plans arising out of accreditation, licensing, and complaint surveys. Consults with and supports clinical and non-clinical leadership in executing and sustaining PDSA plans.
- Facilitates education programs to provide innovative learning experiences for all levels of nursing and other clinical personnel including leadership regarding regulatory and accreditation processes and network performance improvement activities, trends and processes.
- Serves as a network clinical lead with other Regulatory/Accreditation program managers for ISO internal audit process. Responsible for operationalizing the ISO internal auditing function including: preparing and maintaining an annual schedule of internal audits, ensuring all key processes are audited at least annually, and compiling and trending quarterly audit results to identify opportunities to improve network performance. Submits a regular summary of internal audit results to the network ISO Management Representative.
- Participates in the formulation and design of network policies, including strategies based on an awareness of quality of care issues relevant to the healthcare system and regulatory and accrediting agency standards.
Education- Master's Degree - Preferred
- Bachelor's Degree BSN or advanced degree or equivalent in a healthcare field or related discipline (such as Pharmacy, MD, DO) - Required
Experience- 1 year regulatory/accreditation compliance experience, and - Required
- 2 years quality improvement experience or program / project experience. - Required
- 5 years regulatory / accreditation compliance experience in a healthcare environment, and - Preferred
- 5 years quality improvement experience or program/project experience - Preferred
Licenses and Certifications- Arizona license: RN, Pharmacy or Advanced Degree (MPH, MD, DO) - Preferred
- Certified Professional in Healthcare Quality (CPHQ) - Preferred
