RN Regulatory Program Coordinator

SUMMARY:

The Regulatory Program Coordinator serves as the expert resource on regulatory/accreditation and licensure standards and expectations for compliance. Designs and implements a systematic approach to ensure a high level of awareness of regulatory and accrediting agency requirements throughout the organization, including ramifications of failures in compliance. This position will guide the development of policy and guidelines as they relate to the hospital and compliance with regulatory and accreditation guidelines and assist in the interpretation of these policies.

ESSENTIAL FUNCTIONS:

• Provides central expertise regarding accreditation and licensure standards. Identify, plan for, communicate, monitor, and evaluate actions to comply with existing and new regulations, standards and accreditation requirements throughout the organization. Specific duties include timely analysis of regulatory materials, journals, and newsletters for implications on operations; development of working relationships with external agency representatives and key contacts to assist understanding of TMC compliance requirements; and attendance at appropriate educational programs.
• Provides leadership for organizational preparation and readiness for regulatory and accreditation surveys.
• Implements a periodic organizational needs assessment for regulatory compliance including Intra-cycle Monitoring (ICM), using the Focused Standards Assessment (FSA) Tool required by The Joint Commission.
• Identify areas of vulnerability and assist area leaders in developing corrective action plans; also identify and communicate areas of success to celebrate and encourage promotion of best practices.
• Review, assess, and work to revise relevant medical center policies and procedures and/or recommend and assist with the development of new policies and procedures to ensure compliance with regulatory, accreditation, and professional standards.
• Serves as an additional liaison, with the Quality Director, to regulatory agencies and accreditation bodies.
• Provides documentation and other information as required or requested on time to assure compliance for regulating and accreditation agencies. Maintain and organize all critical documentation support in compliance with requirements; oversee the development of delivery and follow-up documentation (i.e. reports, plans, appeals, measures, etc.).
• Manage all agency site visits to include scheduling, logistics and communication within the organization.
• Provides consultation to all departments on the interpretation and application of TJC accreditation standards and Centers for Medicare and Medicaid Services (CMS) Conditions of Participation to maintain ongoing readiness.
• Development of mandatory educational material to meet periodic requirements.
• Assist area leaders in the development of specific educational material to address areas of vulnerability for compliance with standards or unique requirements for special accreditations; assist the medical center in the review of all educational materials for regulatory or accreditation compliance to assure they reflect medical center practice and congruency with each other.
• Adheres to and supports team members in exhibiting TMCH values of integrity, community, compassion, and dedication.
• Adheres to TMCH organizational and department-specific safety and confidentiality policies and standards.
• Performs related duties as assigned.

MINIMUM QUALIFICATIONS

EDUCATION: Bachelor’s degree in nursing from an accredited institution. Master’s Degree preferred. An equivalent combination of relevant education and experience may be substituted for these educational requirements.

EXPERIENCE: Five (5) years nursing experience in a hospital setting.

LICENSURE OR CERTIFICATION: Current RN licensure permitting work in the state of Arizona.

KNOWLEDGE, SKILLS, AND ABILITIES:

·Knowledge of regulatory requirements (TJC and CMS).

·Knowledge of the accreditation process.

·Knowledge of survey preparation and required follow-up activities.

·Skill in written and oral communications.

·Skill in conducting mock regulatory surveys using the tracer methodology.

·Ability to interpret, prepare, and present reports to management in both written and oral formats.

·Ability to make presentations, design and provide training/education to staff and management.