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Quality and Regulatory Specialist

Company: Totally Kids Rehabilitation Hospital
Location: Loma Linda
Posted on: January 15, 2022

Job Description:

Make a Difference. Join Our Great Team!

  • Competitive wages and benefits.
  • Night and weekend differentials.
  • $500 sign-on bonus.
  • Team-centered philosophy of care.About Totally Kids Rehabilitation Hospital
    • Distinctive campus devoted 100% to children
    • National leader in providing rehabilitation and habilitation programs with a family-centered emphasis
    • Consistently awarded the Gold Seal of Approval by the Joint Commission
    • Trusted destination of choice for physicians and parents for more than 50 years.JOB SUMMARY:The Quality/Regulatory Specialist (QRS) directly reports to the Vice President of Regulatory Compliance/Medical Staff Coordinator. This position is detail oriented and requires data base tracking, writing reports, and the ability to multi-task. In collaboration with the Vice President of Regulatory Compliance/Medical Staff Coordinator, the Quality Regulatory Specialist is responsible for leading hospitalwide and system activities to evaluate and improve adherence to state and federal regulatory agencies [i.e. California Department of Public Health (CDPH) and CMS Conditions of Participation (CoPs)] and The Joint Commission (TJC) accreditation standards. This includes facilitating and ensuring ongoing survey readiness for accreditation as well as regulatory self-report and complaint investigations. Identifies opportunities for improvements based on evidence-based practices in regulatory compliance, analysis of internal and external compliance/risk assessments and findings from regulatory authorities.The QRS serves as a resource for interpretation of regulatory and accreditation standards in relation to hospital policies and practices. Conducts patient and system tracers in patient care areas through observation of practice. The QRS also participates in review of event reports to identify potential concerns, track trends and develop preventative measures. Assists in oversight of quality assurance performance improvement (QAPI) teams to ensure goals are achieved. Provides educational opportunities on quality and/or regulatory requirements to staff as assigned.SPECIFIC FUNCTIONAL RESPONSIBILITY:A. Quality
      • Collects data for quality reporting including observations in patient care areas. Provides education in real time to staff as needed.
      • Develops and coordinates processes to monitor quality of care.
      • Utilizes information obtained via performance improvement activities to identify opportunities to improve patient care processes.
      • Demonstrates ability to problem solve, think critically and creatively, and provide assistance to clinical departments
      • Formulates quality action plans, performs root cause analysis and recommends alternative courses of action to reduce potential quality and/or risk concerns or to improve existing processes.
      • Demonstrates knowledge of current methodology and practices and database systems to document occurrences, committee review and actions. Compiles QAPI reports for committees and administrative team.
      • Coordinates data collection and outlines timeframes/reporting requirements for deliverables.B. Regulatory Compliance
        • Assists the Vice President of Regulatory Compliance with coordination of regulatory surveys (The Joint Commission, CMS, CDPH and CCS) and record-keeping
        • Assists Vice President or Regulatory Compliance with workflow development, policy and guideline review/revision, mock survey assessments, and ongoing education
        • Maintains current knowledge of requirements related to CMS Conditions of Participation, The Joint Commission, the California Department of Public Health and California Children's Services (CCS).
        • Interprets regulations, licensure standards and accreditation standards (acute hospital, subacute, and laboratory)
        • Participates in and supports the evaluation of CDPH entity-reported incidents and complaints as needed
        • Gathers necessary documents to support maintenance of and changes to hospital's CDPH licensure. Supports operational leadership and laboratory department leadership to track status of laboratory licenses/CLIA certificates, identify compliance opportunities, and implement of corrective actions
        • Coordinates reviews of patient care contracts, provides technical assistance and monitors compliance to contract.C. Risk Management
          • Develops timelines and assists with analysis of reported events, grievances, and improvement opportunities
          • Communicates relevant clinical risk management findings to appropriate leadership team members
          • Assists with managing and analyzing risk management data including management of event reporting system and tracking events to closure.
          • Audits medical records and monitors performance measures for risk management and sentinel events
          • Assists with FMEA, gap analysis, and event trend analysis
          • Proactively assists VP of Regulatory Compliance in the development and delivery of education programs to all employees to address the risk management process and regulatory guidelinesMISSION STATEMENT: Mountain View Child Care, Inc. is dedicated to enriching the health and quality of life of children with medical and developmental needs and who benefit from habilitation and rehabilitation services and the supportive use of technology. We are committed to meeting their medical, physical, developmental, social, psychological and spiritual needs through a blend of tenderness and expertise.
            CORE VALUES ("iHeart")Integrity: We, the staff of Mountain View Child Care, Inc., (MVCC), choose to achieve wholeness and excellence, in our work by meeting high professional standards and codes of ethics, and we choose to be trustworthy in all our dealings. Likewise, we invite our colleagues and others who represent MVCC to personally strive to meet our high standards. As a guide toward maintaining the integrity of our mission and our daily actions, we align ourselves with the following organization values:Honesty: We foster transparent, honest communication between patients, families, and employees to create a climate of openness in which all persons related to this organization treat one another with trustworthiness and fairness.Excellence: We work at the highest level of sustained performance, with a commitment to continuous improvement.Accountability: We accept responsibility for the ethical and reliable performance of our jobs consistent with industry standards. We are committed to prudent care of our patients and their families and prudence in business practices.Respect: We treat all individuals with compassion, dignity and courtesy.Teamwork: We work together to achieve our mission and goals in a cooperative, respectful, open environment.
            STRATEGIC VISIONCare & Customers: To achieve the best possible results for our patients by working together to improve patient well-being through our Patient & Family Centered Care model.Learning & Growth: To promote a culture of personal and professional growth, thus achieving our strategic objectives by increasing the worth of the individual and the organization.Systems & Reliability: To achieve patient safety by continuously creating or refining processes that increase quality and decrease variability within a high reliability environment.Business & Stewardship: To prudently extend service lines within all MVCC brands to mutually improve quality care, increase business value, and sustain MVCC's long-term mission.
            EXPECTATION FOR ALL EMPLOYEES:To provide service excellence and innovation in the care of patients, the training of health professionals and the creation and sharing of health knowledge. This organization exists to serve others through the expression of the mission, core values, and strategic vision stated above. Requirements:
            • Current California Registered Nurse (RN) or California Respiratory Care Practitioner (RCP) license as issued by the State of California is required
            • Bachelor's degree or equivalent experience in nursing, respiratory, public health, health administration, or health related field preferred or an equivalent combination of education and experience which would provide the required knowledge, skills and abilities may be qualifying
            • Healthcare Accreditation Certified Professional (HACP) or Certified Professional in Healthcare Quality (CPHQ) or ability to achieve certification is required within two years
            • Minimum of three years applicable quality experience such as a quality committee member, involvement in problem-solving teams, management of data, and use of Quality Assurance Performance Improvement (QAPI) tools and techniques required
            • Working knowledge of computer and software applications as applicable to job
            • Attention to detail and problem solving skills with initiative
            • Strong organizational/documentation skills.
              • Possess strong communication, interpersonal and collaboration skills with the ability to interact well with all levels of the organization including administration, professional staff, and front line staff.
              • Must possess good work ethics and a professional image at all times
              • Knowledge of CMS conditions of participation, CDPH state regulations, CCS, and TJC (hospital, nursing care center, and laboratory) accreditation requirements as applicable to job
              • Works responsibly in a team environment as well as independently
              • Manages confidential information effectively and appropriately
              • Ability and willingness to take initiative to address problems and make continuous process improvements.
              • High degree of comfort working with data, using statistical methods to identify trends and using data to drive change.
                • Practice Knowledge
                  • Demonstrates knowledge of current practice and the roles and functions of patient care team members as applicable to job
                  • Ensures compliance with the state and federal regulatory agency standards, and policies of the organization
                  • Adheres to professional association standards of practice as applicable to jobB. Patient Safety/Risk Management
                    • Supports the development of an organization-wide patient safety program
                    • Maintains and ensures patient confidentiality at all times.C. Performance Improvement/Outcome Measurement
                      • Knowledge of the organization's quality assurance performance improvement (QAPI) program
                        • Effective Communication
                          • Demonstrates effective interpersonal communication skills
                          • Provides communications that is clear and effective.
                          • Uses positive verbal/nonverbal communications
                            • Relationship Management
                              • Builds collaborative relationships in the organization
                              • Exhibits effective conflict resolution skills
                                PROFESSIONALISMA. Personally and Professionally Accountable
                                • Holds self and others accountable for mutual professional expectations and outcomes
                                • Adheres to the organization's professional attire (dress code) policy
                                  • Treats our customers' with respect and courtesy. Keeping their information confidential.
                                  • Demonstrates a behavior which is always willing to assist
                                  • Complies with the organization's code of conduct and compliance standards
                                  • Maintains proper use of timekeeping system to record timeB. Career Planner
                                    • Maintains professional license and/or certification as applicable to job
                                    • Acts on feedback about personal strengths and weaknesses
                                    • Completes annual organization education requirements
                                    • Completes annual employee health requirementsC. Trustworthy
                                      • Prudent in showing care for staff organization
                                      • Consistently reliable, truthful and honest
                                      • Ability to hear and convey important and difficult information up and down the organization
                                      • Maintains a level of competency to provide reliable positive outcomes in areas of responsibility

Keywords: Totally Kids Rehabilitation Hospital, Fontana , Quality and Regulatory Specialist, Other , Loma Linda, California

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