DescriptionPenn Medicine is dedicated to our tripartite mission of providing the highest level of care to patients, conducting innovative research, and educating future leaders in the field of medicine. Working for this leading academic medical center means collaboration with top clinical, technical and business professionals across all disciplines.Today at Penn Medicine, someone will make a breakthrough. Someone will heal a heart, deliver hopeful news, and give comfort and reassurance. Our employees shape our future each day. Are you living your life's work?Summary:
Supports Penn Presbyterian Medical Center and those parts of the Clinical Practices of the University of Pennsylvania (CPUP) which practice at or in conjunction with PPMC, operating under the license of said hospital, its leaders and staff to ensure full compliance with federal conditions of participation, state regulations, and accreditation standards. Actively participates in and leads the organization's efforts to prepare for, take part in, and respond to any necessary follow-up of both announced and unannounced regulatory body site visits. Responsibilities also include educating staff to hospital accreditation, disease specific, and licensure standards and regulations. Researches and completes certain applications, as needed by the organization such as Department of Health and other applications / surveys; and The Joint Commission (TJC) e-application survey. Actively works with policy owners to support current and develop new administrative & clinical hospital polices. Supports committee/team projects, and brings groups to consensus on strategies and/or actions necessary to improve compliance to include regulatory, clinical performance, and/or safety outcomes. Develops, maintains, and documents in requisite databases in order to track regulatory activities to ensure continuous process improvement and efficiency within the organization and department. Participates in the regulatory aspects of occupancy surveys. Active in promoting the organization's tracer program.Demonstrates understanding of concepts, methods, techniques and principles needed to accomplish job responsibilities to include but not limited to the Pennsylvania, and New Jersey Department of Health (DOH), The Joint Commission (TJC) and Center for Medicare and Medicaid Services (CMS) regulations. Effective oral and written communicator. High level of initiative and strong business judgment. Comfortable as a team member and informational leader. Works well under pressure while completing tasks quickly and accurately. Complex, abstract problem solving capabilities to maintain system-wide functions. Demonstrates ability to manage, develop, plan and deliver projects with minimal direction. Ability to apply creative thinking to service line themes, content and strategic solutions in a fast-paced environment. Strong analytical abilities, organization and project/process management skill; ability to manage multiple projects simultaneously to achieve goals. Personal Computer, audio/visual equipment, Internet, & various office technologies. Proficiency with computers, spreadsheets, tracer and other databases recommended.Focus on the following regulatory coaching assignments: Assigned provider-based ambulatory sites focused on procedural areas and High Level Disinfection, such as all Central Processing Departments and procedural settings Assigned as lead to PA ASF surveys (Surgery Center and Penn Digestive Liver Health) Assigned complementary inpatient locations for ongoing survey readiness and coaching. Focus on procedures, HLD locations to align with ambulatory assignment Spearhead Disease-Specific Survey: Hip/Knee; VAD; participate in Bariatric Survey Committee/Workgroup Participation based on expertise to include but not limited to the following Perioperative Services Pt. Safety Critical Care Enterprise IT/EPIC optimization Sedation Infection Control Committee Nursing leadership (PRN) Major Lower Joint (CET) Surgery Center Quality, Pt Safety and IC PDLH Quality, Pt. Safety and IC Code Committee/Airway Radiation SafetyPerform regulatory functions for assigned areas; attend other meetings as needed
Responsibilities:
Supports vision of PPMC CMO and Regulatory DepartmentMaintains a solid working knowledge of regulatory body regulations, including but not limited to, TJC, CMS, state regulationsActs as liaison with state and other accrediting bodies as neededResearches and completes surveys which describe institutional demographics, volumes of services, and other activitiesAssesses educational needs, provides information and instructional materials to services/departmentsEnsure internal clients are aware of services offeredEducates staff on key policies & procedures & regulatory requirementsDevelops, documents in, and maintains regulatory related databases necessary to track compliance activities and outcomes.Coordinates and participates in regulatory survey readiness activities to include environment of care rounds and tracersEnsures that all initiatives are in compliance with accrediting, regulatory, & institutional standardsDevelop relationships within the organization to ensure effective communication & partnership / cooperation in all facets of the licensure & accreditation processpromote use of tracer program.Collaborate with leaders & staff to evaluate proposed rules / regulations & assess, develop, or participate in, as appropriate, regulatory advocacy approachesCoordinate with others, as appropriate, to resolve highly complex or unusual business problems impacted by proposed or finalregulatory action or inaction affecting major functions or disciplinesDevelop effective approaches to assess regulatory readiness, collaborating with entity operations in the development of standard processes and procedures.Provide strategic consultation and coordination in the prioritization of major areas of opportunity incorporating both internal best practices as well as external regulatory developments.Convene regulatory workgroups/teams to seek feedback and maximizing transparent sharing of efforts and findings.Support clinical integration across the system by standardizing the writing, review, updating and management of regulatory related policies.Collaborate with entity operations and other departments to develop standard processes and procedures related to regulatory readiness.Facilitates identification of future regulatory-related improvement initiatives and organizes appropriate team members.Coordinates team projects and brings groups to consensus on methods necessary to improve clinical outcomesWith extensive input from and collaboration with entity regulatory directors, prepare routine reports on the state of regulatory readiness at Penn, including major risks and opportunities.Works with individual clinicians & teams to identify methods to improve compliance with clinical performance indicators required By regulatorsMaintains a working knowledge of outcome related publicly reported data and identifies areas where compliance is ProblematicMonitors consistency, validity, & reliability of data. Edits as appropriatePrimary liaison with state agency, including but not limited to PA DOHServes as a liaison with departments such as Pharmacy, Clinical Effectiveness and Quality Improvement (CEQI), Case Management, Infection Control and Prevention, the Medical Staff Departments to identify & solve patient care issues with PPMC managers & staff
Credentials:Education or Equivalent Experience:We believe that the best care for our patients starts with the best care for our employees. Our employee benefits programs help our employees get healthy and stay healthy. We offer a comprehensive compensation and benefits program that includes one of the finest prepaid tuition assistance programs in the region. Penn Medicine employees are actively engaged and committed to our mission. Together we will continue to make medical advances that help people live longer, healthier lives.Live Your Life's WorkWe are an Equal Opportunity and Affirmative Action employer. Candidates are considered for employment without regard to race, ethnicity, color, sex, sexual orientation, gender identity, religion, national origin, ancestry, age, disability, marital status, familial status, genetic information, domestic or sexual violence victim status, citizenship status, military status, status as a protected veteran or any other status protected by applicable law.REQNUMBER: 245939
