Mgr Accreditation and Regulatory Readiness

Summary:

The Manager of Accreditation and Regulatory Readiness reports to the Brown University Health Director Accreditation and Regulatory Readiness. Under general supervision and within Brown University Health established policies and procedures performs a wide variety of duties in managing accreditation and regulatory compliance across Brown University Health including standards and expectations from the Joint Commission (TJC) CMS the Department of Health centers of excellence certification and other related accreditation and regulatory requirements. Ensures that all Brown University Health affiliates maintain continuous compliance with state and federal regulatory and accrediting agencies* standards. Manages complex projects potentially crossing multiple systems platforms and all Brown University Health affiliates. Provides consultation to leadership key stakeholder groups and ad hoc teams on accreditation and other regulatory-related performance improvement activities. Implements improvement strategies and tactics by working collaboratively with other disciplines within Brown University Health.

Responsibilities:

Brown University Health employees are expected to successfully role model the organization*s values of Compassion Accountability Respect and Excellence as these guide our everyday actions with patients customers and one another.

Provides support and leadership for Brown University Health*s Quality Priorities service and treatment settings.

Develops and manages approach to a proactive systematic objective and continuous process of self-assessment of Brown University Health compliance and readiness with all TJC CMS DOH and related regulatory and accreditation standards in partnership with key stakeholders across the system. Develops a process that includes ongoing mock survey audits and tracers for compliance with TJC and CMS standards. Leads and coordinates the interpretation of results and development of action plans across all affiliates to address areas needing improvement.

Guides Brown University Health affiliates to meet external and regulatory standards of TJC CMS and the RI Department of Health. Develops and implements strategies to ensure continuous readiness for external unannounced surveys or reviews. Advises senior management and executive leadership at each affiliate and at the system level of potential vulnerabilities and recommends improvement or corrective actions to maintain compliance.

Develops and implements a robust communication system that effectively informs all involved stakeholders about accreditation requirements implications and changes. Disseminates information clarifying regulatory and accreditation standards and organizes departmental and interdepartmental survey preparation and responses.

Develops and manage a proactive systematic and continuous process for improving readiness and compliance with all standards and requirements for the Brown University Health using a project management approach.

Leads efforts for ongoing accreditation assessment and survey preparation-related activities.

Assists leadership in identifying developing and maintaining needed accreditation-required policies and procedures.

Collaborates with key stakeholders to ensure accreditation-related training and education requirements for Brown University Health staff are met or exceeded. Maintain current working knowledge of all relevant regulatory and accreditation standards.

Performs other duties as assigned.

PERFORMANCE STANDARDS:

Effective utilization of resources

High quality high value patient-focused services

Resource productivity

Fiscal responsibility

Development and implementation of effective quality programs

Customer satisfaction

Performance improvements year-to-year

Positive feedback from peers directs reports and staff

Other information:

QUALIFICATIONS-EDUCATION/CERTIFICATION:

A bachelor*s degree in health administration nursing or healthcare professional field is required. Advanced degree in related field preferred. Must possess a relevant professional certification (e.g. CPHQ or equivalent). Experience with leading managing and supporting organizational accreditation (e.g. Joint Commission CMS) required. Experience with the principles and practices of healthcare quality management preferred. Working knowledge of all Microsoft Office software applications required. A minimum of three years of related work experience is also required. Position requires excellent communication skills including the ability to communicate information effectively to other both verbally and in writing. Position requires the ability to make various presentations internally and externally.

INDEPENDENT ACTION:

Incumbent generally establishes own work plans and priorities including the development and utilization of appropriate strategies methodologies and activities to assure accurate valid and timely completion of work in conformance with organizational and department policies and practices.

SUPERVISION:

Supervises up to 10 FTEs

Brown University Health is an Equal Opportunity employer. All qualified applicants will receive consideration for employment without regard to race color religion sex national origin age ethnicity sexual orientation ancestry genetics gender identity or expression disability protected veteran or marital status. Brown University Health is a VEVRAA Federal Contractor.

Location: Brown University Health Corporate Services USA:RI:Providence

Work Type: Full Time

Shift: Shift 1

Union: Non-Union