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.
This position reports to the Director of Accreditation, Safety, and Regulatory Affairs, Performance Management Division. The position has responsibility and accountability for working to assess, coordinate, plan and organize overall regulatory compliance and readiness (e.g. CMS, DPH, TJC) at Yale-New Haven Hospital, as well as to improve 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 YNHH efforts to improve process efficiencies, assess regulatory compliance and improve overall patient safety and clinical quality.
The Accreditation and Regulatory Specialist provides project management expertise necessary to drive significant breakthroughs. Responsible for independent action in project oversight, systems design and implementation, quality improvement and a variety of special projects. Uses Six Sigma, LEAN, FMEA, change management and acceleration (e.g., CAP, Workout), and/or other available performance improvement methodologies to achieve these goals.
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, TJC, CAP, OSHA, and others. The Accreditation and Regulatory Specialist in collaboration with the Director of Accreditation, Safety and Regulatory Affairs has responsibility for site visit preparation, coordination of site visit logistics and response, as well as to coordinate report-out to management of major regulatory changes and issues and mock or real survey results.
The incumbent will support and coordinate clinical safety and quality activities throughout the institution and ensure that all safety and quality compliance issues are addressed and resolved in a timely manner. In collaboration with the Director Accreditation, Safety and Regulatory Affairs, and others, (e.g. legal office, medical and nursing staff) will ensure that institution-wide policy and procedure changes and revisions are made in relation to regulatory readiness and compliance needs. The incumbent will design and provide educational curricula and evaluation of such for standards and issues related to regulatory compliance.