Job Details

Position Summary:
Partners with the GPA Director of Quality/Regulatory to provide oversight and responsibility for the resources, education, auditing, and corrective action planning required to meet regulatory compliance and accreditation objectives within the Quality Management System of GPA Carle Health, Hospitals, Behavioral Health, and applicable entities within the GPA Carle Physician Group (CPG). Partners with and through leadership, medical staff, nursing staff and the ancillary departments to develop their understanding and accountability for regulatory compliance. Coordinates the development of policies/procedures and strategies to ensure compliance with federal and state regulatory requirements. Objectively and systematically assesses, monitors, evaluates and promotes the improvement of processes that affect the quality of patient care, ensuring regulatory compliance with the acute care hospital standards and critical access hospital standards.

Qualifications:
EDUCATIONAL REQUIREMENTS
Associate's Degree in Any Health Care Field

CERTIFICATION & LICENSURE REQUIREMENTS
Basic Certificate in Quality & Safety (IHI) within 1 year.

EXPERIENCE REQUIREMENTS
Minimum of three years of recent experience in Accrediting Organization preparation and coordination in a hospital setting.

ADDITIONAL REQUIREMENTS

• Registered Nurse (RN) Illinois Licensed-preferred

SKILLS AND KNOWLEDGE
Knowledge of continuous quality improvement theory and statistics, and a strong grasp of the principles and skill set of nursing clinical processes, along with a depth of knowledge of patient safety principles. Strong human relations, influencer, leadership, teamwork management, interpersonal, and communication skills. Ability to facilitate diverse groups/teams. Extensive knowledge of Accrediting Organization standards and requirements. Ability to analyze, interpret and display data. Excellent organizational skills. Advanced presentation skills. Knowledge of quality improvement tools and techniques. Proficiency in Windows environment, MS Word, Excel, and PowerPoint; and ability to readily develop proficiency in any software programs necessary to the position.

Essential Functions:

• Schedules, oversees, and maintains the ISO audit team and assigns audits based on availability and skill set of the auditor. Consults with ISO auditors at GPA Carle Health Facilities to assure each site's ISO audit team is competent and adequately trained.
• Develops, coordinates, oversees, and maintains the mock survey processes, team and makes assignments for the surveyors based on staff availability and skill set. Provides ongoing training and updates for the mock survey team. Coordinates with leaders to conduct mock surveys.
• Provides feedback to leaders regarding the findings from audits, mock surveys, and assigns appropriate corrective actions based on the mock survey findings in partnership with leaders. Provides previous audit, mock survey findings, creates tools for the team to utilize during auditing and mock survey processes.
• Consults with the mock surveyor's team to ensure the competency of the surveyors is maintained. Participates in the System Mock Survey process by coordinating and planning for GPA Carle Health system mock surveys. Serves as an expert clinician and or general surveyor for mock surveys at other Carle facilities.
• Coordinates and oversees the process for annually compiling and submitting corrective action plans required by Accrediting Organization for the maintenance of accreditation status. Coordinates annual assessment of GPA Carle Health Facilities compliance with all accrediting organizations for regulatory requirements.
• Develops and maintains collaborative relationships with department managers/directors, physicians, other Carle systems, and external contacts in order to meet program objectives.
• Develops education and monitoring tools for utilization by all departments to attain the continuous, systematic, and organization-wide improvement necessary for compliance with accreditation and regulatory requirements.
• Responsible for leadership and oversight of the key stakeholders involved in survey preparation and readiness. Assures notification processes and required documentation are current in order to be prepared for the arrival of an unannounced survey team.
• Serves as a consultant to leaders responsible for onsite certification surveys. Provides support and facilitation for onsite certification surveys.
• Maintains and regulatory application, outside regulatory agency website, assist in developing and implementing, if necessary, any plan of corrections.
• Coordinates communication-related to regulatory compliance and survey visits and maintains the Rave notification system relevant to regulatory compliance communication. Provides monthly reporting out of the regulatory compliance program at various committees.
• Assures the maintenance of all regulatory compliance correspondence, and assures the ongoing availability of internal records required for Accrediting Organization on-site survey.
• Coordinates and oversees on-site surveys from the accrediting organizations, DNV GL, Joint Commission, IDPH, CMS, or any other accrediting agency, in partnership with the GPA Director of Quality/Regulatory.
• Maintains up-to-date knowledge of all pertinent standards to which the hospital is accountable. Ensures dissemination of regulatory standards to all key stakeholders, staff, and providers.
• Reviews standards and literature, monitors regulatory websites, and consults with external sources as necessary to remain current with changes in standards and regulations. Works with all departments to develop or revise policies as a result of research, new or existing regulatory requirements.

• This position covers a broad scope of responsibility and is integral to the maintenance of accreditation status and compliance with Medicare's conditions of participation within GPA Carle Health Facilities and numerous off-site locations included. These sites of care are located across an approximate 20-mile distance requiring ongoing travel for this position. This posit