Regulatory Accreditation Specialist

The Regulatory Accreditation Specialist plays a vital role in ensuring delivery of high-quality healthcare services by performing audit activities across the healthcare system. Clinical processes and behaviors important to patient safety, regulatory compliance and quality of care are audited for current adherence of guidelines as well as successful implementation of process change. The Regulatory Accreditation Specialist will report to Accreditation and Regulatory Management leadership. Responsible for performing job duties in accordance with mission, vision and values of Tampa General Hospital. Essential Functions: Collect relevant data by reviewing patient records, conducting interviews, and observing clinical practices within patient care areas of the system. Perform tracers, as directed by leadership for continuous accreditation readiness. Monitor the effectiveness of implemented changes to ensure desired improvements are achieved in response to action planning and formal quality improvement work. Creates and distributes collection tools with data elements that can be collated, trended. Direct and train users on data collection tools, with acceptable inter-rater reliability. Manage data collection, aggregation, and dissemination as directed by leadership. Utilize auditing platforms as to collect and organize findings, utilizing standard reporting tools to assure valid data that is informative and meets standards set for measurement. Collaborate with performance improvement, patient safety, infection prevention and all clinical teams to assure audit tools are complete and appropriate data governance has been followed. Participate in audits and inspections conducted by regulatory bodies or accreditation agencies. Maintain expertise in quality, safety and regulatory indicators and specifications as well as sources of internal measurement and implement new requirements in such measurements. The Regulatory Accreditation Specialist plays a vital role in ensuring delivery of high-quality healthcare services by performing audit activities across the healthcare system. Clinical processes and behaviors important to patient safety, regulatory compliance and quality of care are audited for current adherence of guidelines as well as successful implementation of process change. The Regulatory Accreditation Specialist will report to Accreditation and Regulatory Management leadership. Responsible for performing job duties in accordance with mission, vision and values of Tampa General Hospital. Essential Functions: Collect relevant data by reviewing patient records, conducting interviews, and observing clinical practices within patient care areas of the system. Perform tracers, as directed by leadership for continuous accreditation readiness. Monitor the effectiveness of implemented changes to ensure desired improvements are achieved in response to action planning and formal quality improvement work. Creates and distributes collection tools with data elements that can be collated, trended. Direct and train users on data collection tools, with acceptable inter-rater reliability. Manage data collection, aggregation, and dissemination as directed by leadership. Utilize auditing platforms as to collect and organize findings, utilizing standard reporting tools to assure valid data that is informative and meets standards set for measurement. Collaborate with performance improvement, patient safety, infection prevention and all clinical teams to assure audit tools are complete and appropriate data governance has been followed. Participate in audits and inspections conducted by regulatory bodies or accreditation agencies. Maintain expertise in quality, safety and regulatory indicators and specifications as well as sources of internal measurement and implement new requirements in such measurements. Bachelor's Degree in Nursing or other related field. Minimum three (3) years' experience in a hospital or healthcare related setting with a minimum of two (2) years in quality, risk or regulatory compliance required. Demonstrated experience with The Joint Commission (TJC) and other regulatory agencies or certification survey processes required. Experience with related tools including computer programs such as Word and Excel required. Technical Knowledge, Skills, and Abilities: Clinical experience to provide understanding of clinical terms and roles as well as ability to navigate the EMR. Knowledge of medical terminology, disease processes, treatment modalities. Comfort in clinical settings as observer for audit of real-time clinical processes. Proficiency with reading, analyzing and applying data sets from specific platforms used in the organization. Provides clear, concise written and verbal communication. Attention to detail, organizational skills, and ability to prioritize tasks in a fast-paced environment. Proficiency in using data platforms and Microsoft Office applications. Bachelor's Degree in Nursing or other related field. Minimum three (3) years' experience in a hospital or healthcare related setting with a minimum of two (2) years in quality, risk or regulatory compliance required. Demonstrated experience with The Joint Commission (TJC) and other regulatory agencies or certification survey processes required. Experience with related tools including computer programs such as Word and Excel required. Technical Knowledge, Skills, and Abilities: Clinical experience to provide understanding of clinical terms and roles as well as ability to navigate the EMR. Knowledge of medical terminology, disease processes, treatment modalities. Comfort in clinical settings as observer for audit of real-time clinical processes. Proficiency with reading, analyzing and applying data sets from specific platforms used in the organization. Provides clear, concise written and verbal communication. Attention to detail, organizational skills, and ability to prioritize tasks in a fast-paced environment. Proficiency in using data platforms and Microsoft Office applications.

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