RN Coordinator, Accreditation Regulatory Affairs

Job Description

The Accreditation Coordinator is responsible for the preparation and coordination of efforts related to The Joint Commission and other regulatory compliance; and maintaining a constant state of service readiness for The Daniel Drake Center. This includes maintaining knowledge of all standards, updates to standards and tracking compliance within accreditation database.


Compliance: - 30% Coordinates interpretation and evaluation of compliance with The Joint Commission, ODH, ODMH, and CMS standards. Chairs Regulatory Committees; provides direction for assigned TJC chapter and standard leads. Assists in performing gap analysis of current state of compliance and formulating action plans, responsibilities and completion dates to bring organization into compliance. Maintains a working knowledge and understanding of the intent of standards, regulations, and agency scoring. Reviews official TJC publications and provides summary to department manager and director on a monthly basis. Serves as an expert resource for the intent of the standards and communicates to appropriate personnel, organizational management and physicians. Collaborates and serves as a resource for hospital departments for standards set forth by accrediting and regulatory agencies. Assists departments in assessing, planning, implementing and monitoring activities to assure compliance. Assures adequate and appropriate education and communication relative to standards set by accrediting and regulatory agencies. Attends local and regional workshops to stay abreast of changes or revisions in standards and regulations. Assists in review and evaluation of departmental and organizational programs and policies to ensure that they guide reimbursement, comply with the standards and regulations set forth by TJC and other regulatory agencies. Conducts patient tracers to determine current state of readiness to ensure that the hospital staff is prepared for the accreditation process. Mechanisms are developed and maintained to ensure that line management is aware of the status of departments in regards to compliance. Implements efforts so that the organization is in a constant state of survey readiness. Checks TJC Extranet site every morning for possible survey postings, email communication, new complaints or sentinel event requests for information and communicates to department leadership. Collaborates with CMS/ODMH Coordinator to avoid duplication of efforts. Data Management: - 30% Coordinates data management related to tracking regulatory compliance. Provides routine reports to hospital leadership relative to standards of compliance. Is an expert user for AMP Software system and assists Chapter leads with the scoring and evidence documentation in the system. Maintain ongoing documentation and database related to our required annual Periodic Performance Review. Communicates non-compliance standards, action plans, and measures of success to department leadership. Assists in providing instruction and training to other system users. Assists in creation of reports related to tracking compliance. Validates information posted on the TJC Extranet site monthly and communicates any corrections or additions to department manager. Assists in the planning and coordination of monthly Quality and Safety Day activities. Reviews survey disaster ready documents on a quarterly basis and ensure that data is current. Assists in coordination of training and communication related to regulatory compliance. All conversations with TJC officials are communicated and coordinated with department leadership and documented as needed. Develops, coordinates, and implements both individual and group structured programs in response to learning needs. Principles of adult education and learning theories applied when developing teaching plans and when implementing the instructional process. Assists in the development of content of annually required safety and regulatory information. Promotes a positive working relationship between management, staff, and other departments. Effective communication and interpersonal skills are employed. Effectively integrates change management theory into communication and training activities. Functions as a member of the forms committee and participates on other committees per request. Management is kept informed of the status of activities, problems, and new initiatives. Collaborates with multidisciplinary teams at all levels of management and develops plans for compliance, safety and performance improvement to foster a culture of safety in a non-punitive environment. Works closely with legal services to coordinate review and analysis of incident reports. Analyzes patterns and trends of near miss incidents and initiates recommendations for changes to process or system design to decrease potential for error. Follows up with department and individuals as appropriate.


Minimum Required: Associate's Degree in Health Information Technology Preferred: Bachelor's Degree in Health Information Administration | Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT) | Minimum Required: 5 years