Accreditation and Reg Spec

J  o  b    D  e  s  c  r  i  p  t  i  o  n

JOB INFORMATION

Effective Date:

10/1/2020

Entity:

Wisconsin

Job Code:

300040

Job Title:

Accreditation and Reg Spec

FLSA Exemption Status:

Exempt

Management Level:

Individual Contributor

JOB SUMMARY

Develops and implements organizational initiatives to support accreditation and regulatory continuous readiness.  The scope of a well-developed program encompasses 1) Standard interpretation, 2) Standard compliance, 3) Education and communication, and 4) Survey operations. Promotes a continuous readiness program that emphasizes quality and patient safety at the forefront of regulatory compliance.  Under the direction of the Director, oversees the day-to-day program operations and workflow.  Collaborates with accreditation and regulatory specialists, Director, the organization's content experts, executive sponsors, and medical staff leaders to develop an effective continuous readiness infrastructure that ensures the Program and organizational goals are sustained. Explores opportunities for expanding and standardizing continual readiness initiatives throughout the UW Health enterprise.  Collaborates with colleagues on a national level to enhance UW Health continuous readiness.

ESSENTIAL DUTIES

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Proactively leads the ongoing evaluation, planning and support of the continuous readiness infrastructure and processes to ensure accreditation by deemed status accrediting organizations such as The Joint Commission as well as other regulatory accreditation, certifications, and applicable organizational licenses.

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Support workflow needs and develop strengths of content experts and other accreditation and regulatory leaders to support workflow accordingly. Collaborates regularly with accreditation and regulatory specialists to review work plans and progress. Identifies growth and areas of opportunity to ensure Program initiatives are being met.

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Collaborates with Legal Services, Risk Management, Safety and other departments to assure regulatory functions are addresses

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Identifies regulatory vulnerabilities and determines when significance of vulnerabilities warrants bringing to the attention of the Director and other organizational leaders.

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Leads organization-wide accreditation and regulatory compliance initiatives.

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Develops and manages the meetings and activities of the Accreditation and Regulatory Readiness Committee (ARRC).

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Oversees project prioritization and timeline management of the Accreditation and Regulatory Program.

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Provides guidance on accrediting and certification standards interpretation and other regulatory requirements as they apply to organizational practice.

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Partners with regulatory content experts to identify risk areas and support development, implementation and monitoring of regulatory improvement processes.

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Leads resolution initiatives for complex accreditation and regulatory compliance initiatives.

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Develops tool kits, education and reference materials and provides presentations at manager meetings.

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Ensures regulatory resources are up to date, such as Accreditation Manager Plus (AMP) software program, E-dition standards, and links to the CMS CoPs Interpretive Guidelines and other applicable regulations.

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Develops and implements initiatives to evaluate and monitor compliance with regulatory standards through ongoing organizational assessment, i.e. Intracycle Monitoring, Focused Standards Assessment, tracers, mock surveys and measurement data.

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Tracks and maintains accreditation and certification budget plan; reports information to Director for QRAD budgeting.

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Oversees the development of an organizational communication and education plan for accreditation, i.e. website management, topics for Survey Update, tracers, etc.

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Collaborates with external partners of UW Health.

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Serves as contact and point person for applicable standards-related manuals, publications and newsletters and educational materials; ensures pertinent information is communicated to appropriate individuals.

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Serves as a resource to content experts and executive sponsors in standards and CoP interpretation, insight on upcoming regulatory changes, new requirements, along with exploring options for operationalizing requirements

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Serves as an expert resource and leader in regards to deemed status accrediting organization, such as The Joint Commission accreditation and other regulatory activities and process.

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Plan and coordinate the accreditation and/or regulatory survey

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Serves as a liaison between accreditation / regulatory bodies and the organization.

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Develops, maintains, and implements organizational Unannounced Survey Plan

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Manages onsite accreditation and regulatory surveys, including triaging presentation of surveyors and directing command center activities.

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Manages communications, agendas, and logistics for onsite survey activities.

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Services as liaison between onsite surveyors and organization.

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Assures applications, plans of correction and other required information under the scope of this position are submitted timely.

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Provides expertise and leadership in the development and implementation of action plans including measurement support as needed, for required follow up from the deemed status accrediting organization as well as other regulatory surveys and Intracycle Monitoring.

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Finalizes and submits corrective action responses to regulatory agencies for survey and for-cause and compliant investigations.

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Collaborates with content experts and executive sponsors to ensure corrective action plans are implemented, measures are in place and monitored to sustain accreditation.

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Ensures deemed status accrediting organization applications for accreditation are updated and submitted as required, as accurately as possible.

As needed, additional responsibilities reasonably within the scope of duties and physical requirements may be assigned.  ALL DUTIES AND REQUIREMENTS MUST BE PERFORMED CONSISTENT WITH THE UW HEALTH PERFORMANCE STANDARDS AND RESPECT FOR PEOPLE COMMITTMENTS.

X

Non-Clinical

JOB REQUIREMENTS

Bachelor's Degree

in Nursing, Business, Healthcare Administration, Healthcare Information Management, or a related field, or equivalent combination of experience and education

Required

3 years

Experience working in the healthcare industry. Prior leadership training, classes or experience.  Prior experience with regulatory standards

Required

3 years

Experience with health care compliance and regulatory activities. 2 years with project management experience and leaderesip training/classes/experience

Preferred

LICENSE, CERTIFICATIONS, AND REGISTRATIONS MUST BE MAINTAINED PER UW HEALTH POLICY. 

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Leadership skills

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Knowledge of deemed status accrediting organization standards and regulatory compliance issues

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Experience applying quality management/performance improvement and customer service approaches

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Demonstrated capabilities, with Windows based software applications including word processing, spreadsheets, and database Requires some experience with data analysis and display

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Understanding of standards & regulstions related to clincal documentation with ability to read and assess documentation for compliance, quality and safety (exampleas; H & Ps, Op notes, time Out documentation, Consents; also ability to read a medical record to asses with resonse to regulatory compliance review such as TJC, DQA, CMS and accrediting/regulatory programs

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Excellent verbal and written communication skills.

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Project manage large organization wide initiatives

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Problem solve & make decisions

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Interpret legal and regulatory documents

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Critical thinking for assess appropriate documentation sharing and communication with surveyors

PHYSICAL REQUIREMENTS/WORKING CONDITIONS

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Sedentary: Ability to lift up to 10 pounds maximum and occasionally lifting and/or carrying such articles as dockets, ledgers and small tools. Although a sedentary job is defined as one, which involves sitting, a certain amount of walking and standing is often necessary in carrying out job duties. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Up to 10#

Negligible

Negligible

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Light: Ability to lift up to 20 pounds maximum with frequent lifting and/or carrying of objects weighing up to 10 pounds. Even though the weight lifted may only be negligible amount, a job is in this category when it requires walking or standing to a significant degree.

up to 20#

Up to 10# or requires significant walking or standing or requires pushing/pulling of arm/leg controls.

Negligible or constant push/pull of items of negligible weight

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Medium: Ability to lift up to 50 pounds maximum with frequent lifting and/or carrying objects weighing up to 25 pounds.

20-50#

10-25#

Negligible-10#

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Heavy: Ability to lift up to 100 pounds maximum with frequent lifting and/or carrying objects weighing up to 50 pounds.

50-100#

25-50#

10-20#

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Very Heavy: Ability to lift over 100 pounds with frequent lifting and/or carrying objects weighing over 50 pounds.

Over 100#

Over 50#

Over 20#

Other - list any other physical requirements or bona fide occupational qualifications not indicated above:

Note: The purpose of this document is to describe the general nature and level of work performed by personnel so classified; it is not intended to serve as an inclusive list of all responsibilities associated with this position.

THE EMPLOYEE MUST BE ABLE TO COMPLETE ALL PHYSICAL REQUIREMENTS OF THE JOB WITH OR WITHOUT AN APPROVED ACCOMODATION. Note: The purpose of this document is to describe the general nature and level of work performed by personnel so classified; it is not intended to serve as an inclusive list of all responsibilities associated with this position.