Location: TriHealth Corporate Office

Work Hours: Full-Time, 40 hours weekly, Day Shift, No weekends or holidays

Minimum Job Requirements:

Education:

Master’s degree in Healthcare, Allied Health, or a related field. In lieu of a Master’s degree, candidates may qualify with relevant healthcare experience If no Master’s degree is held, the following are required:

            * 3–5 years of experience in accreditation and/or regulatory compliance

            * Certification in a relevant area within 1 year of hire

Licensure:

Must maintain current healthcare licensure

Technical & Professional Skills:

Proficiency with Microsoft Office applications Strong communication and organizational skills Experience with data collection and analysis Familiarity with root cause analysis and/or other process improvement methodologies Project planning and coordination experience Involvement in and preparation for accreditation surveys

Experience:

5–7 years of professional healthcare and clinical experience 3–4 years of progressive leadership experience in nursing

Job Overview:

Provides leadership and coordination of compliance with Joint Commission, ACHC, and other accrediting bodies accreditation standards, CMS Conditions of Participation, and State regulatory requirements for TriHealth facilities.  Assumes responsibility and accountability for the development and maintenance of systems and functions that support and ensure ongoing compliance with standards and regulations, and continuous regulatory readiness.   Duties include: project plan development and management; coordination of participation in the Ohio Continuous Survey Readiness Program; management of onsite regulatory and accreditation  surveys; provide survey support for the clinical service lines for certification surveys, leader and team member  education; continuous readiness visits/mock  tracers; identification and communication of opportunities to improve compliance to leadership and team members, and communication and education of changes in accrediting bodies standards, CMS regulations, and State requirements. Role requires working with multiple stakeholders, managing multiple priorities, performance coaching, conflict management, and communicating complex concepts.

The incumbent shall provide support in maintaining accreditation applications; fulfillment of Accreditation Participation Requirements; resolution of Requirements for Improvement (RFI’s); development and submission of Evidence of Standards Compliance (ESC’s) and Plan of Corrections (POC); The position will assist with the regulatory compliance application and will promote the utilization of the application including providing user training.

As assigned, other duties might include project plan development and management, coordination of change management, and logistical planning.  

Job Responsibilities:

Successfully builds and utilizes partnerships, collaborating with hospital and medical staff leadership and other management in effectively planning, implementing and overseeing activities to assess, maintain and improve compliance with requirements of CMS Conditions of Participation and accrediting bodies to ensure continuous full hospital accreditation. This should include development of new process and structures, identification of change leadership strategies and the identification and resolution of barriers. 

Effective and timely completion of all duties to maintain accreditation applications responsibilities including application for survey; renewal applications, fulfillment of Accreditation Participation Requirements; and any process related accreditation cycle such as Joint Commission Incidents. 

Effective and timely completion of all duties related to pre survey, intra survey and post survey phases of regulatory and accreditation surveys, responsibilities including preparing required documents and survey prep for surveys, assisting/coordinating actual survey, facilitating/coordinating resolution of Requirements for Improvement and Citations; development and submission of Evidence of Standards Compliance; development and coordination of regulatory Corrective Plans of Actions

Maintains knowledge of accrediting bodies and regulatory bodies requirements and utilizing knowledge to drive improvement and compliance, assisting, leaders, team members and medical staff to maintain regulatory compliance. 

Maintenance of continuous survey regulatory readiness, developing and implementing a plan for the organization to rapidly and effectively respond to an unannounced survey visit.  Able to utilize tools (such as electronic tracers, reports, data analysis) to maintain regulatory readiness.


Working Conditions:

Concentrating - Frequently Continuous Learning – Consistently Interpersonal Communication - Consistently Thinking/Reasoning - Consistently 

TriHealth SERVE Standards and ALWAYS Behaviors
At TriHealth, we believe there is no responsibility more important than to SERVE our patients, our communities, and our fellow team members. To achieve our vision and mission, ALL TriHealth team members are expected to demonstrate and live the following: 

Serve: ALWAYS…
• Welcome everyone by making eye contact, greeting with a smile, and saying "hello"
• Acknowledge when patients/guests are lost and escort them to their destination or find someone who can assist
• Refrain from using cell phones for personal reasons in public spaces or patient care areas
Excel: ALWAYS…
• Recognize and take personal responsibility to address and recover from service breakdowns when a customer's expectations have not been met
• Offer patients and guests priority when waiting (lines, elevators)
• Work on improving quality, safety, and service 
Respect: ALWAYS…
• Respect cultural and spiritual differences and honor individual preferences.
• Respect everyone’s opinion and contribution, regardless of title/role.
• Speak positively about my team members and other departments in front of patients and guests.
Value: ALWAYS…
• Value the time of others by striving to be on time, prepared and actively participating.
• Pick up trash, ensuring the physical environment is clean and safe.
• Be a good steward of our resources, using supplies and equipment efficiently and effectively, and will look for ways to avoid waste.
Engage: ALWAYS…
• Acknowledge wins and frequently thank team members and others for contributions.
• Show courtesy and compassion with customers, team members and the community