Regulatory Specialist
Company: Yale New Haven Health
Location: Madison
Posted on: February 25, 2021
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Job Description:
OverviewThis position reports to a Yale New Haven Health System
Manager of Accreditation and Regulatory Affairs Department, Office
of the Chief Quality Officer. The position has responsibility and
accountability for working to assess, coordinate, plan and organize
overall regulatory compliance and readiness (e.g. CMS, DPH, TJC) at
Yale-New Haven Health hospital delivery networks, as well as to
improve key processes, policies and procedures as they relate to
regulatory compliance. Works as an internal consultant with medical
staff, nursing, support services, and other departments to plan,
organize, facilitate, implement and measure YNH Health efforts to
improve process efficiencies, assess regulatory compliance and
improve overall patient safety and clinical quality. The
Accreditation and Regulatory Specialist provides project management
expertise necessary to drive significant breakthroughs. Responsible
for independent action in project oversight, systems design and
implementation, quality improvement and a variety of special
projects. Uses Six Sigma, LEAN, FMEA, change management and
acceleration (e.g., CAP, Workout), and/or other available
performance improvement methodologies to achieve these goals. In
conjunction with Hospital Departments and Committees; e.g. Legal
Office, the Hospital Safety Committee, Laboratory Medicine and
Performance Management colleagues, works to assess the impact of
quality projects on clinical operations as well as gauge readiness
and compliance for internal and external surveys, and adverse event
and complaint investigations by CMS, DPH, TJC, and others as
needed. The Accreditation and Regulatory Specialist in
collaboration with the Manager of Accreditation and Regulatory
Affairs has responsibility for site visit preparation, coordination
of site visit logistics and response, as well as to coordinate
report-out to management of major regulatory changes and issues of
mock or real survey results. The incumbent will support and
coordinate clinical safety and quality activities throughout the
health system hospital delivery networks and ensure that all safety
and quality compliance issues are addressed and resolved in a
timely manner. In collaboration with the Manager Accreditation and
Regulatory Affairs, and others, (e.g. legal office, medical and
nursing staff) will ensure that system and institution-wide policy
and procedure changes and revisions are made in relation to
regulatory readiness and compliance needs. The incumbent will
design and provide educational tools and curricula and evaluation
of such for standards and issues related to regulatory
compliance.Responsibilities1.--As necessary, leads, facilitates and
coordinates projects to improve clinical and non-clinical areas.
Provides leadership in meeting goals and objectives. Interacts with
Managers, Staff, Department Heads, Clinical Service Coordinators,
Vice Presidents, and Chiefs of respective departments in relation
to projects.2.--Uses Six Sigma, CAP, LEAN, Workout and other
methodologies to achieve process improvement and to enhance
clinical quality and patient safety. Facilitates integration of
methodology with quality improvement goals of the
departments.3.--Provides key regulatory safety and quality data
highlighting business and operational issues requiring management
attention and resources.4.--Participates in hospital task forces,
charters and committees to provide operational input and regulatory
consultation.5.--Facilitates the coordination and completion of
multidisciplinary efforts in regard to regulatory preparedness and
completion of applications (e.g. Hospital Accreditation and
Licensure, CMS Database Forms, FSA/PPR completion, measurement of
success data, DPH or CMS corrective action plans, and clinical
charter teams with).6.--Provides leadership, guidance and
facilitation to clinical and non-clinical departments and serves on
multiple hospital committees to continually assess aspects of
Hospital JC/DPH/CMS readiness and compliance.7.--In conjunction
with other JC/Regulatory Committee members, coordinates and leads
tracer rounds (mock surveys) to assess compliance with regulatory
requirements and helps prioritize and remediate to improve
performance.8.--Facilitates and provides coordination of
adverse/sentinel event and complaint investigations, root cause
analysis, and ensures related improvement plans are met for safety
issues recognized by JC, DPH and CMS for the Health
System.9.--Develops and manages action plans and measurements of
success processes in collaboration with functional and departmental
leaders to ensure institution-wide oversight of all regulatory
compliance needs related to CMS, DPH and TJC.10.--Verifies and
validates evidence of action plans and measurements of success data
related to regulatory compliance issues institution-wide for the
health system designated hospital delivery networks.11.--Works
collaboratively with the Medical Directors, Director of the
Hospitalist Team, Service and Department Safety and Quality
Committees, and other clinical leaders, to set goals/assess
Hospital delivery network(s) performance, prioritize resources,
implement change through facilitation and other activities, and
assess project success.12.--Ensures compliance with regulatory
standards (TJC, CMS, DPH, etc.) for quality and safety reporting
through collaboration with the Manager Accreditation and Regulatory
Affairs and others as relevant.13.--In collaboration with Manager
Accreditation and Regulatory Affairs develops and disseminates mock
and real survey issues related to regulatory standards and hospital
policy compliance.14.--Creates and develops strategic educational
and training programs and tools relating to compliance issues,
safety and quality issues, and continuous regulatory
readiness.15.--Collaborates with YNHHS peers for system-wide
collaboration on TJC and DPH readiness. May provide
expertise/teaching for YNHHS Institute for Excellence.16.--Other
projects, assignments and responsibilities as
indicated.EDUCATIONCurrent healthcare licensure, RN preferred (e.g.
RN, LCSW, RT/OT) in the state of Connecticut or Rhode Island, or
the equivalent healthcare experience, and an MBA, MPH, MSN, or
other Masters degree in health-related field, or current enrollment
with completion within one year is required.EXPERIENCEFive (5) to
seven (7) years of progressive clinical experience with three (3)
to five (5) years of experience in program management, demonstrated
teaching experience, and process improvement with clinical
operations with experience in high level analytical tools.
Six-Sigma, LEAN, or other formal process improvement training
preferred. Experience and knowledge of TJC standards, CMS
Conditions of Participation and experience with accreditation
survey process required.
Keywords: Yale New Haven Health, New England , Regulatory Specialist, Other , Madison, Northeast
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