Manager Regulatory Accreditation
Apply NowCompany: Skagit Regional Health
Location: Mount Vernon, WA 98273
Description:
Department: Quality Management SRH
Exempt: Yes
Schedule: DAYS - VARIABLE
Position Type: Full Time 0.6 FTE or More
FTE: 1.000000
Base Wage: $ 50.00 to $ 75.01
Location: Skagit Valley Hospital
The information described in this job description has been designed to indicate the general nature of the work performed. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities and qualifications required of employees assigned to this job.
Other information:
Job Summary
The Manager of Regulatory and Accreditation is dedicated to optimizing and maintaining regulatory and accreditation systems within Skagit Regional Health. This role manages the Regulatory and Accreditation team reporting to the Regional Director of Quality and Reliability within the Quality Division, promoting a culture of regulatory compliance throughout the organization and overseeing all mandatory requirements.
Essential Functions
Lead the accreditation awareness and preparedness activities. Chair the Clinical Quality and Standards Committee to ensure all stakeholders are aware of and are actively striving to achieve regulatory readiness and maintaining compliance.
Act as a liaison, in alignment with Quality Division leadership members' direction and approach, with regulatory bodies and representatives in the process of facilitating regulatory compliance and managing regulatory and accreditation processes. Ensure that all leaders and entities are prepared for announced and unannounced regulatory visits, surveys and investigations. Plan ahead and set reasonable cadence to meet all submission deadlines. Act as SRH's ISO Management Representative.
Facilitate the response to regulatory findings through the corrective action plan processes. Ensure corrective action plans address root and apparent causes. Design action plans in collaboration with area leaders and executive sponsors in such a manner that action plans are accomplished with desired outcomes in the limited time allotted.
Manage and document the internal and external auditing processes following all regulatory requirements and best practices. Ensure auditing process is cohesive and integrated into the Quality Management System. Coordinate efforts with quality data analysts to share auditing data in a meaningful and actionable manner.
Conduct ongoing assessments of accreditation readiness. Brief leadership regarding readiness, creating action plans for improvement as needed and assuring actions are implemented to maintain compliance. Actively participate in and collaboratively lead multi-disciplinary hazard rounds. Design and conduct regular mock surveys. Identify and communicate risk associated with observed practices.
Manage all documents and the associated document management system representing SRH's practices, including but not limited to policies, procedures, protocols, and scopes. Facilitate timely engagement of leaders. Ensure documents represent compliant practices, recommending policy and procedure changes to improve care and patient outcomes. Oversee the policy and procedure committees that review and approve the documents as well as the associated workflows.
Recommend actions using risk-based thinking to improve compliance measures with an eye to patient safety, effectiveness and efficiency. Suggest priorities for improvements aligned to the strategic plan.
Monitor mandatory requirements; receive and analyze DNV, CMS, DOH and all regulatory program materials. Distribute these in professionally condensed versions to create meaning for the leaders receiving the information and materials. Facilitate to ensure alignment as needed with current SRH practices.
Communicate regulatory goals and outcomes to the organization in methods and forums supported by the Quality Management System, including but not limited to the Executive Quality Oversight Council.
Bring the patient to every conversation to promote patient-centered and timely processes.
Consult with leaders and work groups to help identify, plan and trend quality projects as well as to understand, interpret, meet and even exceed regulatory requirements.
Communicate effectively and cooperatively in the workplace. Attend and actively participate in all department, team and/or committee meetings. Comply with all Skagit Regional Health, department and location specific policies and procedures. Perform other duties as assigned by Supervisor or designee.
Required local (45-mile radius) travel regularly to perform duties at all enterprise locations, including two hospitals, all hospital outpatient services and multiple clinical service sites.
Education
Required BSN/BS/BA or Degree in health care related field or business administration with equivalent work experience. Preferred Master's Degree in public health, other healthcare related field or business administration.
Experience/Training
Requires a minimum of 5 years of clinical and/or regulatory compliance experience required. Highly desired experience with DNV accreditation and ISO 9001 standards. Desired knowledge of IHI improvement methodologies, continuous quality improvement, Lean Six Sigma and education methods.
License/Certifications
Current and unrestricted Washington State Registered Nurse license required. Joint Commission Professional (CJCP) Certification or Det Norske Veritas Certification required within 18 months of hire, only required one time. Certification in Healthcare Quality (CPHQ) required within 24 months of hire.
Other Skills
Hands-on clinical experience with practice in quality and process improvement. Experience with integrated healthcare delivery systems experience or demonstrated knowledge of hospital and clinic practice standards. Demonstrated application of regulatory standards. Exceptional leadership skills to include change management. Ability to work independently as well as with small and large groups of healthcare professionals, providers, and others in the organization to problem solve, set priorities, plan and schedule workload to meet deadlines.
Physical Demands and Work Environment
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. While performing the duties of this job, the employee is regularly required to sit for long periods of time; when working in office. Repetitive tasks such as typing, sitting, answering phones, and interacting with computers and computer systems most of the day is a function of the position. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to focus. This position requires working in an indoor, environmentally controlled environment when in the office.
Skagit Regional Health offers a comprehensive benefit package including medical, dental, vision, 457b/401a (retirement), long term disability, and paid time off to all employees holding an FTE of 20 or more hours per week. Eligible employees also receive sick time pay.
Exempt: Yes
Schedule: DAYS - VARIABLE
Position Type: Full Time 0.6 FTE or More
FTE: 1.000000
Base Wage: $ 50.00 to $ 75.01
Location: Skagit Valley Hospital
The information described in this job description has been designed to indicate the general nature of the work performed. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities and qualifications required of employees assigned to this job.
Other information:
Job Summary
The Manager of Regulatory and Accreditation is dedicated to optimizing and maintaining regulatory and accreditation systems within Skagit Regional Health. This role manages the Regulatory and Accreditation team reporting to the Regional Director of Quality and Reliability within the Quality Division, promoting a culture of regulatory compliance throughout the organization and overseeing all mandatory requirements.
Essential Functions
Lead the accreditation awareness and preparedness activities. Chair the Clinical Quality and Standards Committee to ensure all stakeholders are aware of and are actively striving to achieve regulatory readiness and maintaining compliance.
Act as a liaison, in alignment with Quality Division leadership members' direction and approach, with regulatory bodies and representatives in the process of facilitating regulatory compliance and managing regulatory and accreditation processes. Ensure that all leaders and entities are prepared for announced and unannounced regulatory visits, surveys and investigations. Plan ahead and set reasonable cadence to meet all submission deadlines. Act as SRH's ISO Management Representative.
Facilitate the response to regulatory findings through the corrective action plan processes. Ensure corrective action plans address root and apparent causes. Design action plans in collaboration with area leaders and executive sponsors in such a manner that action plans are accomplished with desired outcomes in the limited time allotted.
Manage and document the internal and external auditing processes following all regulatory requirements and best practices. Ensure auditing process is cohesive and integrated into the Quality Management System. Coordinate efforts with quality data analysts to share auditing data in a meaningful and actionable manner.
Conduct ongoing assessments of accreditation readiness. Brief leadership regarding readiness, creating action plans for improvement as needed and assuring actions are implemented to maintain compliance. Actively participate in and collaboratively lead multi-disciplinary hazard rounds. Design and conduct regular mock surveys. Identify and communicate risk associated with observed practices.
Manage all documents and the associated document management system representing SRH's practices, including but not limited to policies, procedures, protocols, and scopes. Facilitate timely engagement of leaders. Ensure documents represent compliant practices, recommending policy and procedure changes to improve care and patient outcomes. Oversee the policy and procedure committees that review and approve the documents as well as the associated workflows.
Recommend actions using risk-based thinking to improve compliance measures with an eye to patient safety, effectiveness and efficiency. Suggest priorities for improvements aligned to the strategic plan.
Monitor mandatory requirements; receive and analyze DNV, CMS, DOH and all regulatory program materials. Distribute these in professionally condensed versions to create meaning for the leaders receiving the information and materials. Facilitate to ensure alignment as needed with current SRH practices.
Communicate regulatory goals and outcomes to the organization in methods and forums supported by the Quality Management System, including but not limited to the Executive Quality Oversight Council.
Bring the patient to every conversation to promote patient-centered and timely processes.
Consult with leaders and work groups to help identify, plan and trend quality projects as well as to understand, interpret, meet and even exceed regulatory requirements.
Communicate effectively and cooperatively in the workplace. Attend and actively participate in all department, team and/or committee meetings. Comply with all Skagit Regional Health, department and location specific policies and procedures. Perform other duties as assigned by Supervisor or designee.
Required local (45-mile radius) travel regularly to perform duties at all enterprise locations, including two hospitals, all hospital outpatient services and multiple clinical service sites.
Education
Required BSN/BS/BA or Degree in health care related field or business administration with equivalent work experience. Preferred Master's Degree in public health, other healthcare related field or business administration.
Experience/Training
Requires a minimum of 5 years of clinical and/or regulatory compliance experience required. Highly desired experience with DNV accreditation and ISO 9001 standards. Desired knowledge of IHI improvement methodologies, continuous quality improvement, Lean Six Sigma and education methods.
License/Certifications
Current and unrestricted Washington State Registered Nurse license required. Joint Commission Professional (CJCP) Certification or Det Norske Veritas Certification required within 18 months of hire, only required one time. Certification in Healthcare Quality (CPHQ) required within 24 months of hire.
Other Skills
Hands-on clinical experience with practice in quality and process improvement. Experience with integrated healthcare delivery systems experience or demonstrated knowledge of hospital and clinic practice standards. Demonstrated application of regulatory standards. Exceptional leadership skills to include change management. Ability to work independently as well as with small and large groups of healthcare professionals, providers, and others in the organization to problem solve, set priorities, plan and schedule workload to meet deadlines.
Physical Demands and Work Environment
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. While performing the duties of this job, the employee is regularly required to sit for long periods of time; when working in office. Repetitive tasks such as typing, sitting, answering phones, and interacting with computers and computer systems most of the day is a function of the position. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to focus. This position requires working in an indoor, environmentally controlled environment when in the office.
Skagit Regional Health offers a comprehensive benefit package including medical, dental, vision, 457b/401a (retirement), long term disability, and paid time off to all employees holding an FTE of 20 or more hours per week. Eligible employees also receive sick time pay.