Bachelor's Degree in Nursing or advanced healthcare-related field required
Master's Degree preferred
1 year of regulatory/accreditation compliance experience required
2 years of quality improvement or project experience required
5 years of regulatory/accreditation compliance experience in healthcare preferred
5 years of quality improvement or project experience preferred
Arizona RN, Pharmacy license, or advanced degree preferred
Responsibilities
Ensure compliance with federal and state regulations and accreditation standards across the network
Lead clinical regulatory and accreditation compliance teams for survey readiness
Assess clinical performance and coordinate corrective actions for patient safety issues
Facilitate education programs on regulatory processes and performance improvement
Operationalize ISO internal auditing functions and report on audit results
Participate in policy formulation based on quality care and regulatory standards
Collaborate with nursing and quality staff on performance improvement initiatives
Benefits
Full-time position with a Monday to Friday schedule
Opportunity to lead and innovate in regulatory compliance
Engagement with diverse teams across the healthcare network
Access to continuous education and professional development
Involvement in shaping healthcare policies and quality improvement initiatives
Full Job Description
Primary City/State: Osborn Medical Center - 7400 E Osborn Rd Scottsdale, AZ 85251 Category: Operations Shift: Day Department: Quality Improvement Division Full Time, Mon-Fri
Responsibilities: Job Summary Provides 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
Certified Professional in Healthcare Quality (CPHQ) - Preferred
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About HonorHealth
HonorHealth is a non-profit healthcare organization that provides medical services to patients in Arizona. The organization operates six acute care hospitals, outpatient centers, and primary care clinics. HonorHealth's services include cancer care, heart and vascular care, neurosciences, orthopedics, and women's health. The organization also provides research and clinical trials, as well as education and training programs for healthcare professionals. HonorHealth was founded in 2013 and is headquartered in Scottsdale, Arizona.
