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USC Verdugo Hills Hospital · 1 month ago

Quality and Regulatory Specialist - Quality Assurance - Full Time 8 Hour Days (Exempt)(Non-Union)

Los Angeles, CA - Health Sciences Campus

Full-time

Onsite

Mid Level

$81K/yr - $133K/yr

3+ years exp

USC Verdugo Hills Hospital is seeking a Quality and Regulatory Specialist to lead system-wide activities for accreditation and regulatory compliance. The role involves ensuring ongoing survey readiness, consulting with quality teams, and collaborating with healthcare staff to improve organizational performance and patient safety.

Hospital & Health Care

Responsibilities

Assesses survey readiness and ensures all implementation of all applicable Patient Safety initiatives

Evaluates prior survey deficiencies and current survey standards for compliance

Coordinates and provides leadership for survey readiness rounds and provides a rotating calendar of visits to different healthcare facilities

Complies and disseminates information to the applicable senior director and CMO on areas that require action to ensure compliance

Ensures all quality and patient safety rounds, identify opportunities to improve care and outcomes

Identifies, develops, and evaluates quality improvement initiatives particularly as they relate to regulatory agencies

Trains and develops other departmental personnel in quality improvement and regulatory oversight

Gathers, identifies trends and solutions for the leadership team including but not all inclusive: KPI, Utilization, Patient satisfaction, After hours care

Prepares reports for leadership presentations

Provides consultation to individuals/departments concerning regulatory standards and assists with interpretation of new or revised standards; Recommends methods/actions to achieve regulatory compliance; Serves as a consultant for other projects as assigned

Implements corrective actions including but not limited to providing written responses to any RFI’s (Recommendation for improvement), or audit deficiencies related to regulatory compliance

Ensures that the applicable database is updated with any corrective action plans and follows up with the applicable department director regarding the proposed action plan

Collaborates with all members of the healthcare team to promote an organized approach to the hospital’s survey process

Facilitates survey readiness teams

Cross-trained in the functions of Quality and Outcomes Management and Peer Review processes to collaborate with department staff members and provide coverage as necessary

Communicates any audit findings to the senior director and CMO along with any proposed or implemented action plans

Attends any applicable hospital or medical staff committee meetings to communicate information on Survey Readiness

Provides In-service to clinical staff and medical staff as appropriate to ensure survey preparedness

Oversight of incidents reporting systems, trending of incidents

Presentations of trends

Keeps updated on all regulations that pertain to organization licensure and updates policies and procedures as necessary

Member of the policy and forms committee and works closely with the policy coordinator

Provides supervision and oversight for regulatory compliance staff ensuring a cohesive well informed team

Performs other duties consistent with professional training and experience and department goals and functions

Qualification

Regulatory complianceAccreditation standardsQuality improvementHealthcare administrationPatient safetyCross-functional collaborationTrainingDevelopmentIncident reportingData analysisCommunication

Required

Bachelor's degree Health-Related Professions Degree in healthcare administration, nursing, or related field required

3-5 years of regulatory, accreditation, and quality improvement experience

Working knowledge of regulatory agencies accreditation and regulatory requirements

Ability to facilitate working sessions with cross-functional teams

Certified Professional in Healthcare Quality - CPHQ (NAHQ) CPHQ or HACP certification within 2 years of hire

Fire Life Safety Training (LA City) If no card upon hire, one must be obtained within 30 days of hire and maintained by renewal before expiration date (Required within LA City only)