Partners with the GPA Director of Quality/Regulatory to provide oversight and responsibility for the resources, education, auditing, and corrective action planning required to meet regulatory compliance and accreditation objectives within the Quality Management System of GPA Carle Health, Hospitals, Behavioral Health, and applicable entities within the GPA Carle Physician Group (CPG). Partners with and through leadership, medical staff, nursing staff and the ancillary departments to develop their understanding and accountability for regulatory compliance. Coordinates the development of policies/procedures and strategies to ensure compliance with federal and state regulatory requirements. Objectively and systematically assesses, monitors, evaluates and promotes the improvement of processes that affect the quality of patient care, ensuring regulatory compliance with the acute care hospital standards and critical access hospital standards.
Qualifications
Certifications: IHI Open School Basic Certificate in Quality and Safety within 1 year - Institute for Healthcare Improvement (IHI), Education: Associate's Degree, Work Experience:
Responsibilities
Schedules, oversees, and maintains the ISO audit team and assigns audits based on availability and skill set of the auditor. Consults with ISO auditors at GPA Carle Health Facilities to assure each site's ISO audit team is competent and adequately trained. Develops, coordinates, oversees, and maintains the mock survey processes, team and makes assignments for the surveyors based on staff availability and skill set. Provides ongoing training and updates for the mock survey team. Coordinates with leaders to conduct mock surveys. Provides feedback to leaders regarding the findings from audits, mock surveys, and assigns appropriate corrective actions based on the mock survey findings in partnership with leaders. Provides previous audit, mock survey findings, creates tools for the team to utilize during auditing and mock survey processes. Consults with the mock surveyor's team to ensure the competency of the surveyors is maintained. Participates in the System Mock Survey process by coordinating and planning for GPA Carle Health system mock surveys. Serves as an expert clinician and or general surveyor for mock surveys at other Carle facilities. Coordinates and oversees the process for annually compiling and submitting corrective action plans required by Accrediting Organization for the maintenance of accreditation status. Coordinates annual assessment of GPA Carle Health Facilities compliance with all accrediting organizations for regulatory requirements. Develops and maintains collaborative relationships with department managers/directors, physicians, other Carle systems, and external contacts in order to meet program objectives. Develops education and monitoring tools for utilization by all departments to attain the continuous, systematic, and organization-wide improvement necessary for compliance with accreditation and regulatory requirements. Responsible for leadership and oversight of the key stakeholders involved in survey preparation and readiness. Assures notification processes and required documentation are current in order to be prepared for the arrival of an unannounced survey team. Serves as a consultant to leaders responsible for onsite certification surveys. Provides support and facilitation for onsite certification surveys. Maintains and regulatory application, outside regulatory agency website, assist in developing and implementing, if necessary, any plan of corrections. Coordinates communication-related to regulatory compliance and survey visits and maintains the Rave notification system relevant to regulatory compliance communication. Provides monthly reporting out of the regulatory compliance program at various committees. Assures the maintenance of all regulatory compliance correspondence, and assures the ongoing availability of internal records required for Accrediting Organization on-site survey. Coordinates and oversees on-site surveys from the accrediting organizations, DNV GL, Joint Commission, IDPH, CMS, or any other accrediting agency, in partnership with the GPA Director of Quality/Regulatory. Maintains up-to-date knowledge of all pertinent standards to which the hospital is accountable. Ensures dissemination of regulatory standards to all key stakeholders, staff, and providers. Reviews standards and literature, monitors regulatory websites, and consults with external sources as necessary to remain current with changes in standards and regulations. Works with all departments to develop or revise policies as a result of research, new or existing regulatory requirements. This position covers a broad scope of responsibility and is integral to the maintenance of accreditation status and compliance with Medicare's conditions of participation within GPA Carle Health Facilities and numerous off-site locations included. These sites of care are located across an approximate 20-mile distance requiring ongoing travel for this position. This position provides direction and support to the medical staff, leadership and associates for maintaining and achieving the measures necessary for regulatory compliance, patient safety and quality outcomes.
About Us
Find it here.
Discover the job, the career, the purpose you were meant for. The supportive and inclusive team where you can thrive. The place where growth meets balance – and opportunities meet flexibility. Find it all at Carle Health.
Based in Urbana, IL, Carle Health is a healthcare system with nearly 16,600 team members in its eight hospitals, physician groups and a variety of healthcare businesses. Carle BroMenn Medical Center, Carle Foundation Hospital, Carle Health Methodist Hospital, Carle Health Proctor Hospital, Carle Health Pekin Hospital, and Carle Hoopeston Regional Health Center hold Magnet® designations, the nation’s highest honor for nursing care. The system includes Methodist College and Carle Illinois College of Medicine, the world’s first engineering-based medical school, and Health Alliance™. We offer opportunities in several communities throughout central Illinois with potential for growth and life-long careers at Carle Health.
We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class. Carle Health participates in E-Verify and may provide the Social Security Administration and, if necessary, the Department of Homeland Security with information from each new employee's Form I-9 to confirm work authorization. | For more information: human.resources@carle.com.
Compensation and Benefits
The compensation range for this position is $32.51per hour - $55.92per hour. This represents a good faith minimum and maximum range for the role at the time of posting by Carle Health. The actual compensation offered a candidate will be dependent on a variety of factors including, but not limited to, the candidate’s experience, qualifications, location, training, licenses, shifts worked and compensation model. Carle Health offers a comprehensive benefits package for team members and providers. To learn more visit careers.carlehealth.org/benefits.