Accreditation and Regulatory Specialist

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Greenwich, CT
Jul 22, 2020


Job Description


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 a Yale New Haven Health System Manager of Accreditation and Regulatory Affairs Department, Office of the Chief Quality Officer. 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 Health hospital delivery networks, 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 YNH Health 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, and others as needed. The Accreditation and Regulatory Specialist in collaboration with the Manager of Accreditation 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 of mock or real survey results. The incumbent will support and coordinate clinical safety and quality activities throughout the health system hospital delivery networks and ensure that all safety and quality compliance issues are addressed and resolved in a timely manner. In collaboration with the Manager Accreditation and Regulatory Affairs, and others, (e.g. legal office, medical and nursing staff) will ensure that system and 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 tools and curricula and evaluation of such for standards and issues related to regulatory compliance.



  • 1. As necessary, leads, facilitates and coordinates projects to improve clinical and non-clinical areas. Provides leadership in meeting goals and objectives. Interacts with Managers, Staff, Department Heads, Clinical Service Coordinators, Vice Presidents, and Chiefs of respective departments in relation to projects.
  • 2. Uses Six Sigma, CAP, LEAN, Workout and other methodologies to achieve process improvement and to enhance clinical quality and patient safety. Facilitates integration of methodology with quality improvement goals of the departments.
  • 3. Provides key regulatory safety and quality data highlighting business and operational issues requiring management attention and resources.
  • 4. Participates in hospital task forces, charters and committees to provide operational input and regulatory consultation.
  • 5. Facilitates the coordination and completion of multidisciplinary efforts in regard to regulatory preparedness and completion of applications (e.g. Hospital Accreditation and Licensure, CMS Database Forms, FSA/PPR completion, measurement of success data, DPH or CMS corrective action plans, and clinical charter teams with).
  • 6. Provides leadership, guidance and facilitation to clinical and non-clinical departments and serves on multiple hospital committees to continually assess aspects of Hospital JC/DPH/CMS readiness and compliance.
  • 7. In conjunction with other JC/Regulatory Committee members, coordinates and leads tracer rounds (mock surveys) to assess compliance with regulatory requirements and helps prioritize and remediate to improve performance.
  • 8. Facilitates and provides coordination of adverse/sentinel event and complaint investigations, root cause analysis, and ensures related improvement plans are met for safety issues recognized by JC, DPH and CMS for the Health System.
  • 9. Develops and manages action plans and measurements of success processes in collaboration with functional and departmental leaders to ensure institution-wide oversight of all regulatory compliance needs related to CMS, DPH and TJC.
  • 10. Verifies and validates evidence of action plans and measurements of success data related to regulatory compliance issues institution-wide for the health system designated hospital delivery networks.
  • 11. Works collaboratively with the Medical Directors, Director of the Hospitalist Team, Service and Department Safety and Quality Committees, and other clinical leaders, to set goals/assess Hospital delivery network(s) performance, prioritize resources, implement change through facilitation and other activities, and assess project success.
  • 12. Ensures compliance with regulatory standards (TJC, CMS, DPH, etc.) for quality and safety reporting through collaboration with the Manager Accreditation and Regulatory Affairs and others as relevant.
  • 13. In collaboration with Manager Accreditation and Regulatory Affairs develops and disseminates mock and real survey issues related to regulatory standards and hospital policy compliance.
  • 14. Creates and develops strategic educational and training programs and tools relating to compliance issues, safety and quality issues, and continuous regulatory readiness.
  • 15. Collaborates with YNHHS peers for system-wide collaboration on TJC and DPH readiness. May provide expertise/teaching for YNHHS Institute for Excellence.
  • 16. Other projects, assignments and responsibilities as indicated.



Current healthcare licensure, RN preferred (e.g. RN, LCSW, RT/OT) in the state of Connecticut or Rhode Island, or the equivalent healthcare experience, and an MBA, MPH, MSN, or other Masters degree in health related field, or current enrollment with completion within one year is required.


Five (5) to seven (7) years of progressive clinical experience with three (3) to five (5) years of experience in program management, demonstrated teaching experience, and process improvement with clinical operations with experience in high level analytical tools. Six-Sigma, LEAN, or other formal process improvement training preferred. Experience and knowledge of TJC standards, CMS Conditions of Participation and experience with accreditation survey process required.


Proven analytical/problem-solving skills. Outstanding communication, presentation and facilitation skills. Strong computer skills (e.g., Microsoft PP and Excel) and demonstrated ability to successfully lead process change are needed. Strong management, communication, and planning skills are required. Knowledge and experience of CAP, Workout and LEAN preferred. Strong healthcare clinical background essential.


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Job Info

Job: 15642

Department: Accreditation and Reg Affairs
Sub Category: ADMIN PROF
Status: Full Time Benefits Eligible
Shift: DAYS
Hours: 40

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