Accreditation and Regulatory Compliance Specialist - Quality (1.0 FTE, Days)

Category: Quality
Job Type: Full-Time
Shift: Days
Req: 14358
FTE: 1


1.0 FTE, 8 Hour Shift Day 

At Stanford Children’s Health, we know world-renowned care begins with world-class caring. That's why we combine advanced technologies and breakthrough discoveries with family-centered care. It's why we provide our caregivers with continuing education and state-of-the-art facilities, like the newly remodeled Lucile Packard Children's Hospital Stanford. And it's why we need caring, committed people on our team - like you. Join us on our mission to heal humanity, one child and family at a time.

Job Summary

This paragraph summarizes the general nature, level and purpose of the job. 

In collaboration with the Director of Accreditation, The Accreditation and Regulatory Compliance Specialist manages all aspects of accreditation, regulatory and hospital licensure compliance across the healthcare enterprise. Provides consultation to healthcare enterprise leadership and managers on accreditation readiness through participation in operational committees, communication, facilitation and project management. Communicates with involved organizational personnel about accreditation/regulatory requirements, implications to the healthcare environment and strategies to reliably achieve compliance. Identifies opportunities for improvements based on evidence based practices in regulatory and accreditation compliance, analysis of internal and external compliance/risk assessments and findings from regulatory authorities.

 Essential Functions

The essential functions listed are typical examples of work performed by positions in this job classification.  They are not designed to contain or be interpreted as a comprehensive inventory of all duties, tasks, and responsibilities.  Employees may also perform other duties as assigned.

Employees must abide by all Joint Commission Requirements including but not limited to sensitivity to cultural diversity, patient care, patient rights and ethical treatment, safety and security of physical environments, emergency management, teamwork, respect for others, participation in ongoing education and training, communication and adherence to safety and quality programs, sustaining compliance with National Patient Safety Goals, and licensure and health screenings.

Must perform all duties and responsibilities in accordance with the hospital’s policies and procedures, including its Service Standards and its Code of Conduct.

  • Leverages experience in accreditation and regulatory survey processes and builds upon 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, with an emphasis on hospital, laboratory, and home care expectations. 
  • Develops and delivers education regarding internally and externally driven trends in healthcare licensure, accreditation and regulatory compliance. Assists managers and staff with workflow development, policy and procedure review/revision, mock survey assessments, and ongoing education
  • Leads accreditation/regulatory efforts involving LPCH leaders and departments to assess policies, evaluate workflows, observe clinical care, interview team embers, assess environment of care, etc. with goal of identifying gaps, consulting on priority of items needing correction, researching and advising on reliable compliance strategies utilizing evidence-based practice. Helps to create reliable quality assurance processes to monitor success of corrective action plans
  • Assists Directors of Accreditation and Regulatory Compliance, Quality Management, Patient Safety and Professional Practice Evaluation, and Infection Prevention and Control in facilitating an integrated organizational approach to assessing and meeting regulatory requirements and process improvements
  • Partners with operational leaders and relevant support departments e.g. Patient Safety, Infection Control, to develop corrective action plans and to track the success of corrective actions
  • Consistently aligns priorities of accreditation and regulatory compliance efforts with hospital's culture of safety and PCARES programs. Supports efforts to ensure compliance to the National Patient Safety Goals
  • Partners with Directors of Accreditation and Regulatory Compliance and Patient Safety to reliably identify and report applicable safety incidents to CDPH in a timely manner. Participates in and supports the evaluation of CDPH entity-reported incidents and complaints as needed
  • Gathers and submits 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 to implement of corrective actions
  • Helps to provide direction to Accreditation and Regulatory Compliance Department Coordinator in collection of required CCS certification materials and participates in onsite CCS surveys, as needed
  • Assists Director with coordination of regulatory surveys by Joint Commission, CMS, CDPH and CCS. Supports department-specific surveys by regulatory and accreditation authorities such as FDA, DEA, CAP, CMS Transplant, CMS End Stage Renal Disease, etc., as needed

 Minimum Qualifications

Any combination of education and experience that would likely provide the required knowledge, skills and abilities as well as possession of any required licenses or certifications is qualifying.

Education: Bachelor's degree in a work-related field/discipline from an accredited college or university. Preferred: Masters degree.

Experience: Required: Three (3) years of progressively responsible and directly related work experience. Preferred: 5 years of experience.

License/Certification: None required. Preferred: RN, RT, Pharmacist

License/Certification Preferred: Healthcare Accreditation Certification Program (HACP), Certified Professional in Healthcare Quality (CPHQ), Certified Joint Commission Professional (CJCP), Institute of Healthcare Improvement (IHI)

 Knowledge, Skills, & Abilities

These are the observable and measurable attributes and skills required to perform successfully the essential functions of the job and are generally demonstrated through qualifying experience, education, or licensure/certification.

  • Knowledge of the principles and practices of accreditation and regulatory compliance, including, in particular, their application in an academic medical center
  • Knowledge of project management and change management methodologies and tools
  • Knowledge of and ability to apply performance improvement methodologies and tools to projects (e.g., A3 thinking, PDCA, value stream and process mapping, root cause analysis, etc.)
  • Knowledge of computer systems and software used in functional area
  • Knowledge and proficiency in the use of Microsoft Office Suite of applications and clinical documentation systems (preferably EPIC)
  • Ability to communicate effectively to facilitate positive working relationships and achieve desired outcomes
  • Ability to lead interdisciplinary groups to review high-risk workflows, identify compliance gaps, and facilitate development and reliable implementation of solutions
  • Excellent interpersonal skills and is talented at leading the efforts of multidisciplinary team initiatives.

 Physical Requirements

The Physical Requirements and Working Conditions in which the job is typically performed are available from the Occupational Health Department. Reasonable accommodations will be made to enable individuals with disabilities to perform the essential functions of the job

Equal Opportunity Employer

Lucile Packard Children’s Hospital Stanford strongly values diversity and is committed to equal opportunity and non-discrimination in all of its policies and practices, including the area of employment. Accordingly, LPCH does not discriminate against any person on the basis of race, color, sex, sexual orientation or gender identity, religion, age, national or ethnic origin, political beliefs, marital status, medical condition, genetic information, veteran status, or disability, or the perception of any of the above. People of all genders, members of all racial and ethnic groups, people with disabilities, and veterans are encouraged to apply. Qualified applicants with criminal convictions will be considered after an individualized assessment of the conviction and the job requirements, and where applicable, in compliance with the San Francisco Fair Chance Ordinance.



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