Job Summary

Maintain the system on continual survey readiness for all entities. Collaborates with leaders for developing, implementing, maintaining, and enhancing mechanisms to track, trend, and report accreditation & regulatory compliance measures and reports to the NCHS. Assist and/or lead in the preparation, coordination, and execution of efforts related to major accreditations or equivalent national accreditation entities and other regulatory & governmental agency surveys. Maintains expert knowledge of Federal, States, and Accreditation standards and updates to standards and regulatory requirements through analysis, documentation, reporting of data, and summarizing.

Job Specific Duties

• Serves as a expert resource for interpretation of state, regulatory, accreditation, and disease-specific care certification standards (as applicable) in relation to system wide policies and practices.
  
• Performs routine ISO internal audit tracers, through interviews, document review, and survey assessments to assist in determining compliance with accreditation and regulatory standards and requirements within clinical and non-clinical departments in the hospital, Outpatient Care Centers, and any additional healthcare settings.
  
• Collects, analyzes, trends, and reports data in support of continuous survey readiness activities and efforts. Standardizes reports for Accreditation and Regulatory department.
  
• Identifies and evaluates the organization's risk areas and provides key input in the development of the annual risk-based ISO internal audit plan.
  
• Maintain centralized databases and sources of information for Accreditation & Regulatory continuous survey readiness program.
  
• Interprets, analyzes, and disseminates the results of ISO internal monitoring tools and surveillance results in a timely manner.
  
• Assists in assuring accuracy and timeliness in submission to all accreditation and regulatory reporting requirements.
  
• Participates in department and system wide initiatives by compiling and analyzing data, including comparison of outcome measures to benchmark, identify trends, and complete gap analysis.
  
• Assists in the identification of activities to reach performance goal and metric set forth by the Accreditation & Regulatory Department.
  
• Actively participates in system wide or department specific preparation for accreditation and regulatory audits/surveys by creating and maintaining compliance roadmaps.
  
• Provides or assists in providing training, coaching, and guidance to NCHS staff in conducting accreditation readiness and ISO internal monitoring activities.