Accred/Regulatory Program Manager

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Duke Health Lake Norman Hospital

Pursue your passion for caring with Duke Health Lake Norman Hospital in Mooresville, North Carolina. The smallest of Duke Health’s four hospitals at 123-beds, it offers a comprehensive range of medical services, including 24-hour emergency care, cardiology, orthopedics, women's services, and surgical specialties.

General Description of the Job Class

The Accreditation and Regulatory Program Manager position is responsible for collaborating, at a system/entity level, with leadership, staff and medical staff to provide a proactive, global and unified perspective and understanding of accreditation, regulatory and disease specific certification requirements and activities. The Accreditation and Regulatory Program Manager, is a systems thinker playing a pivotal role in leading system/entity efforts to achieve the highest compliance with accreditation and certification standards with an approach to ensuring practices not only meet but exceed benchmarks for patient care excellence. This role collaborates in shaping and supporting the framework for ongoing accreditation success, by leveraging extensive knowledge in regulations, standards and improvement methodologies. The position serves the system/entity organization as a resource, mentor, and educator for regulatory, accreditation and certification programs; working across the organization to assess, measure, and report ongoing compliance with standards, promote evidence-based best practices, and standardize common survey processes. The Accreditation and Regulatory Program Manager collaborates with system/entity operational, executive and medical staff leadership to operationalize an effective continuous readiness infrastructure that ensures and sustains the DUHS Accreditation and Regulatory Program goals of 1) Standard interpretation, 2) Standard compliance, 3) Education and communication, and 4) Survey operations. This role includes programmatic ownership of Accreditation and Regulatory activities, ensuring strategic alignment and execution of related initiatives.

Duties and Responsibilities of this Level

Lead continuous readiness efforts:

Proactively leads the ongoing evaluation, planning and support of the continuous compliance and readiness infrastructure and processes to ensure accreditation by deemed status organizations as well as other regulatory accreditation, certifications and applicable organizational licenses.

Supports workflow needs and develop strengths of content experts and leadership to support workflows.

Collaborate with Patient Safety, Quality, Professional Practice, Risk Management, Legal and other departments to ensure regulatory functions are assessed and in compliance with standards.

In partnership with system/entity leadership identifies accreditation or regulatory risks or vulnerabilities and supports operational leaders in the development, implementation and monitoring of regulatory improvement processes.

Directly leads and manages system/entity-wide accreditation and regulatory compliance initiatives, tracking and monitoring corrective actions.

Co-leads with operations, system/entity-wide accreditation and regulatory compliance initiatives and tracks and monitors corrective actions.

Provides guidance on accrediting and certification standards interpretation and other regulatory requirements as they apply to clinical practice.

In partnership with system/entity leadership, establishes processes to conduct ongoing proactive review of regulatory, accreditation and certification standards.

Develops and implements initiatives to evaluate and monitor compliance with regulatory standards through ongoing organizational assessment (Intracycle monitoring, Focused Standards Assessment, tracers, mock surveys and measurement data).

Supports and participates, as requested, in entity pre-survey, on-site survey and post-survey activities for accreditation, regulatory and certification programs.

Co-ordinates and participates in system/entity internal surveys using process audit tools and techniques to assess and evaluate ongoing survey readiness.

Participation in the development, review and evaluation of ongoing system/entity regulatory and accreditation program that promotes continual improvement of compliance with standard requirements. Serves as an expert in identifying high risk and patient safety sensitive processes and ensures activities are in place for ongoing risk assessment.

Conducts ongoing monitoring, measurement and analysis of survey data and trends, communicates aggregate results and analyses to appropriate entity departments, staff and leadership. Partners with leadership to implement risk reduction and continuous compliance activities.

Monitors standards of care opportunities identified during Survey Readiness Assessments, works with system/entity clinical operations teams and leadership to create output from these learnings; including updated policy and guidance statements, education materials, training sessions.

Provides subject matter expertise in conducting Survey Readiness Assessments for system/entity in preparation for accrediting and regulatory surveys. Maintains survey tracker and archiving of survey documents.

Regularly audits thoroughness and effectiveness of documentation as a way to evaluate proactive survey compliance practices.

Resource development and management:

Develops toolkits, education and reference materials and provides educational opportunities and presentations.

Ensures regulatory resources are up to date, such as Accreditation Manager Plus (AMP) software program, E-dition standards and links to the CMS Conditions of Participation Interpretive Guidelines and other applicable guidelines/resources.

Develops system/entity specific communication and education plans for accreditation and regulatory.

Provides education and training related to regulatory, accreditation and disease specific certification requirements.

Conducts ongoing review of policies, procedures and practices to ensure alignment with current standards.

Supports system/entity operational leaders to develop, review and update policies and procedures as needed to remain in compliance with accreditation, certifications and regulatory requirements.

Directly leads and manages system/entity-wide accreditation and regulatory compliance initiatives, tracking and monitoring corrective actions.

Serves as an educational resource and leader in accreditation, regulatory and certification:

Serves as system/entity contact and point person for applicable standards-related manuals, publications and newsletters and educational materials; ensures pertinent information is communicated to appropriate individuals.

Serves as system/entity expert resource and leader in regards to deemed status accrediting organization and other regulatory or certification agencies.

Serves as system/entity resource to other content experts and executive sponsors in standards and CoP interpretation, insight on upcoming regulatory changes and new requirements. Collaborates with system/entity operational leaderships on options for operationalizing the requirements.

Enhances continuous improvement activities by acquiring, utilizing and teaching performance and process improvement concepts and methodologies such as LEAN, PDCA, DMAIC.

Remains current with regulatory, accreditation and certification changes through available resources such as conferences or internet-based learning, reviewing and researching specific program materials and/or reviewing professional journals.

Collaborates with system/entity clinical, administrative and support departments/committees/councils to implement changes and improvements that enhance compliance with standards and excellence in patient outcomes.

Implements, in partnership with entity and system leadership, Policy and Clinical Document improvement processes to include review, initiation, revision, archiving.

Coordinate accreditation, regulatory or certification surveys:

Serves as a liaison between accreditation/regulatory bodies and the entity.

Develops, maintains and implements entity specific unannounced survey plan.

Co-manages with entity organizational leadership on-site accreditation, regulatory and certification surveys.

Provides management of communications, agendas and logistics for entity on-site survey activities.

May serve as the liaison between on-site surveyors and the entity being surveyed and may serve as first point of contact for surveyors.

In partnership with system/entity leadership, establishes a process to conduct a proactive review or regulatory, accreditation and certification to assess vulnerabilities to compliance with standards.

Collaborates and effectively communicates with a wide variety of disciplines within the system/entity to provide support and guidance and evaluate, improve and sustain regulatory and accreditation readiness. Fosters cooperation among departments and disciplines to achieve and sustain ongoing accreditation and regulatory compliance.

Co-manage ongoing application requirements and corrective action plans:

Collaborates with entity leadership to assign teams to develop corrective action in response to survey findings and facilitate development and implementation or a corrective action plan.

Ensures that applications, plans of correction and other required information under the scope of this position are submitted timely.

Provides expertise and support for entity leadership in the development and implementation of action plans including measurement support as needed for required follow-up from accrediting organizations, regulatory surveys and Intracycle monitoring.

Provides support for the development and submission of corrective action plans/responses to regulatory agencies for survey and for cause and complaint investigations after finalization by system/entity leadership/operations.

Collaborates with content experts and entity executive leaderships to ensure corrective action plans are implemented, measures are in place and monitored to sustain accreditation or certification.

Ensures entity specific deemed status accrediting organization applications for accreditation are updated and submitted as required and as accurately as possible.

Facilitates resolution of entity survey non-compliance though monitoring the progress of corrective action plans on an ongoing basis. Conducts system/entity internal surveys with survey teams to review and evaluate the implementation, effectiveness and sustainability of survey corrective action plans; provides reports from the surveys to entity/system l

Required Qualifications at this Level

Education

Bachelor's degree in Nursing, Business, Healthcare Administration. Master's degree preferred.

Experience

5 years of experience working with accreditation, certification, quality, risk management, patient safety or clinical operations. 2 years of healthcare/medical/nursing/patient care experience is preferred.

Must have knowledge of quality improvement methodologies, project management and regulatory standards; including at least CMS, TJC, DNV, DOH.

Must be able to work on-site to ensure readiness for unannounced surveys.

Preferred qualifications: Management experience, especially with clinical operations in a clinical healthcare environment preferred. Experience with auditing/data analytics, staff training and creative problem solving preferred. Previous accreditation readiness experience, experience with project management systems/leadership experience strongly preferred.

Degrees, Licensure, and/or Certification

RN or other clinical professional with current licensure preferred.

Preferred certifications:

CPHQ - Certified Professional Healthcare Quality or;

Certified Quality Technician - ASQ or;

HACP - Healthcare Accreditation Program or;

CSHA - Certified Specialist in Healthcare Accreditation

Knowledge, Skills, and Abilities

Knowledge of deemed status accrediting organization standards and regulatory compliance issues.

Experience applying quality management/performance improvement and customer services approaches.

Management/project management skills.

Strong problem solving, analytical and negotiating skills paired with strong attention to detail.

Ability to develop, prioritize and accomplish goals.

Positive interpersonal skills; establish relationships and interact and work effectively in a team environment. Ability to influence others who have no direct reporting relationship.

Strong analytical, facilitation, coaching, written and verbal skills.

Flexible with changes, processes and procedures to meet program/plan needs.

Ability to use discretion/use independent judgment when obtaining, compiling and distributing information and data required.

Experience within an organization with complex relationships and multiple stakeholders that may have conflicting goals and priorities

Demonstrated ability to manage conflict, build, support, mentor and monitor teams and the ability to recognize and address positive behaviors that contribute to successful achievement of plan goals

Highly self-motivated, self-directed and independent thinker using independent judgment while being a strong resource and team player for the team.

Distinguishing Characteristics of this Level

N/A

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