PFCI Accreditation Spec

Summary

Summary 

Oncology Regulatory Compliance and Accreditation Subject Matter Expert (SME):

Serves as the Accreditation SME for the Parkview Packnett Family Cancer Institute, affiliates and satellites; reports directly to the Accreditation/Multi-Disciplinary Supervisor. Has direct responsibility for accreditation activities within the PFCI as identified by PFCI Executive Leadership and the Oncology Clinical Program Director.

Collaborates with all PFCI clinical teams, the Data, Quality & Metrics team, the Tumor Board Specialist team, and the Mirro Research team to ensure accreditation requirements are being met. Maintains contact with all clinical teams responsible for standard compliance throughout the accreditation programs.

Provides clear education related to standards to clinical teams. Ensures PFCI compliance with the following clinical accreditations: The Commission on Cancer (CoC), The National Accreditation Program for Breast Centers (NAPBC), and the National Accreditation Program for Rectal Centers (NAPRC). Monitors all standard releases for updates and works with all teams to ensure guidelines are being followed and policies and procedures are current and compliant.

Establishes quarterly meetings and required reporting for all accreditations. Is an expert in Microsoft Planner where documentation and task assignment and deadlines are identified.

Serves as the clinical coordinator for the NAPRC accreditation, monitors Tumor Board documentation review weekly, and works with the DQM to ensure all IS documentation requirements are updated when guideline standards are updated.

Attends all surveys and prepares all stakeholders in advance for surveys. Completes minutes for surveys, tracks action items, and submits data to the Pre-Review Questionnaire (PRQ) within designated timeline. Supports Parkview's satellite and business partner locations with Oncology accreditation needs.

Education 

Bachelor's degree in health related field required.

Licensure/Certification 

If degree is in Nursing must have a valid Indiana RN licensure. ODS certification preferred.

Experience 

Minimum of five years in an Oncology related role. Experience in Oncology quality accreditation/assessment/performance improvement, regulatory compliance, data analysis and reporting preferred.

Other Qualifications 

Proven ability to collaborate with multi-disciplinary teams in a direction that fulfills the mission and goals of PH and PFCI. Is able to utilize technology such as Excel, Microsoft Office, and Planner to track and meet deadlines required for accreditation. Works well with teams to plan, implement and evaluate change. Excellent written and verbal communication skills. Working knowledge of quality report interpretation, knowledge of EPIC/other electronic health records preferred. Familiar with databases and technical build of discrete data.

Must possess strong customer service skills and coworker development skills. Demonstrated ability to work collaboratively and effectively with physicians and care teams. Possesses strong critical thinking skills. Ability to lead physicians and peers in a positive, collaborative and professional manner. Demonstrates knowledge through education or experience in Oncology clinical workflows and accreditation guidelines. Must have skills/knowledge related to the position's technical and clinical setting including working knowledge of Oncology State and Federal submission requirements, and hospital regulatory requirements.