Regulatory Specialist

Overview:
To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values - integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day.

The position has responsibility and accountability for working to assess, plan, and organize overall regulatory compliance and readiness (e.g. CMS, DPH/DOH, TJC) at the assigned Yale New Haven Health hospital delivery network(s), as well as to participate in the improvement of key processes, policies and procedures as they relate to regulatory compliance.

Works as an internal consultant with medical staff, nursing, support services, and other departments to plan, organize, facilitate, implement and measure delivery network efforts to improve process efficiencies, assess regulatory compliance and improve overall patient safety and clinical quality.

The Regulatory Specialist provides project management experience necessary to support significant breakthroughs. Responsible for independent action in project oversight, systems design and implementation, quality improvement and a variety of special projects.

In conjunction with Hospital Departments and Committees; e.g. Legal Office, the Hospital Safety Committee, Laboratory Medicine and Performance Management colleagues, works to assess the impact of quality projects on clinical operations as well as gauge readiness and compliance for internal and external surveys, and adverse event and complaint investigations by CMS, DPH/DOH, TJC, and others as needed.

The Regulatory Specialist under the supervision of the Director of Accreditation and Regulatory Affairs has responsibility for site visit preparation, coordination of site visit logistics and response, as well as assist in preparing report-out to management of major regulatory changes and issues of mock or real survey results. The Regulatory Specialist supports activities associated with site visits.

The incumbent will support and coordinate clinical safety and quality activities throughout the health system hospital delivery networks and ensure that all safety and quality compliance issues are addressed and resolved in a timely manner.

The incumbent will design and provide educational tools and curricula and evaluation of such for standards and issues related to regulatory compliance.

EEO/AA/Disability/Veteran

Responsibilities:

• 1. As necessary, acts as a key member of projects to improve clinical and non -clinical areas. Partners with internal and external departmental leadership in meeting goals and objectives. Interacts with Managers, Staff, Department Heads, Clinical Service Coordinators, Vice Presidents, and Chiefs of respective departments in relation to projects.
• 2. Acts as an active participant in departmental process improvement to enhance clinical quality and patient safety.
• 3. Provides key regulatory safety and quality data highlighting business and operational issues requiring management attention and resources.
• 4. Participates in hospital task forces, charters and committees to provide operational input and regulatory consultation. Participates in the coordination and completion of multidisciplinary efforts in regard to regulatory preparedness and completion of applications (e.g. Hospital Accreditation and Licensure, CMS Database Forms, ICM completion, measurement of success data, DPH/DOH or CMS corrective action plans, and clinical charter teams).
• 5. Creates, develops, and delivers educational and training programs and tools relating to compliance issues, safety and quality issues, and continuous regulatory readiness.
• 6. Provides consultation to clinical and non-clinical departments and serves on multiple hospital committees to continually assess aspects of Hospital DPH/DOH readiness and compliance.
• 7. In conjunction with other JC/Regulatory Committee members, coordinates tracer rounds (mock surveys) to assess compliance with regulatory requirements and helps prioritize and remediate to improve performance.
• 8. Facilitates and provides coordination of adverse/sentinel event and complaint investigations, root cause analysis, and ensures related improvement plans are met for safety issues recognized by JC, DPH/DOH, and CMS in conjunction with other committee members.
• 9. Under the supervision of the department leadership, supports action plans and measurements of success processes in collaboration with functional and departmental leaders to ensure institution-wide oversight of all regulatory compliance needs related to CMS, DPH/DOH and TJC.
• 10. Under the supervision of department leadership, verifies and validates evidence of action plans and measurements of success data related to regulatory compliance issues for departments or individual action plans in the health system designated hospital delivery networks. Collaborates with department leadership prior to document submission to an external agency.
• 11. Works collaboratively with the unit and service level medical staff, to set goals /assess Hospital delivery network(s) performance, prioritize resources, implement change through facilitation and other activities, and assess individual project success.
• 12. Ensures compliance with regulatory standards (TJC, CMS, DPH/DOH, etc.) for quality and safety reporting under the direction of the Director Accreditation and Regulatory Affairs and others as relevant.
• 13. In collaboration with Director Accreditation and Regulatory Affairs develops and disseminates mock and real survey issues related to regulatory standards and hospital policy compliance.
• 14. Other projects, assignments, and responsibilities as indicated.

EDUCATION

Current healthcare licensure preferred (e.g. RN, LCSW, RT/OT) in the state of Connecticut or Rhode Island, or the equivalent healthcare experience. An advanced degree (MBA, MPH, MSN, or other Masters degree in health related field) or current enrollment is required. Certification (HACP, CJCP, CPHQ are examples) is preferred.

EXPERIENCE

Three (3) to five (5) years of progressive healthcare experience with one (1) to three (3) years of experience in program management, demonstrated teaching experience, and process improvement with clinical operations.

Experience and knowledge of TJC standards, CMS Conditions of Participation and experience with accreditation survey process preferred.

LICENSURE

Current healthcare licensure preferred (e.g. RN, LCSW, RT/OT)

SPECIAL SKILLS

Proven analytical/problem-solving skills. Outstanding communication, presentation and facilitation skills.

Strong computer skills (e.g., Microsoft PP and Excel) and demonstrated ability to successfully lead process change are needed.

Program or project management, effective communication, and planning experience are required.

Healthcare background is required.