Mgr. Accreditation & Regulatory Affairs

New London, CT
Jun 7, 2019

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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.

EEO/AA/Disability/Veteran

Summary:
Directly Reports To The Executive Director, Accreditation & Regulatory Affairs, And Works Collaboratively With Members Of Senior Operations Group, Management Teams, And Medical Staff Leadership. Have Responsibility And Accountability To Provide Direction, Planning, Oversight And Consultation To Ensure Accreditation, Safety, Licensing, And Regulatory Mandates Are Met (E.G. Cms, Dph, Tjc) At Lawrence + Memorial (L+M) And Westerly Hospital (Wh). In Conjunction With The Executive Director, Accreditation & Regulatory Affairs, Works To Improve Key Processes, Policies And Procedures As They Relate To Accreditation, Safety And Regulatory Affairs. Serves As The Hospital?S Liaison To Accrediting And Regulatory Agencies. Works To Continuously Improve Patient-Safety With The Goal Of Maximizing Patient Safety And High-Quality Patient Care. Provides Overall Direction Necessary To Ensure That Clinical Services Are Provided In Accordance With Established Accreditation And Licensing Standards, State And Federal Regulations.

Responsibilities:
  • 1. Consults Routinely With Executive, Corporate Legal Counsel, Risk Management, And/Or Operations Mangers On Accreditation, Licensing, Safety And Regulatory Compliance Issues.
  • 2. As Necessary, Leads, Facilitates And Coordinates Projects To Improve Clinical And Non-Clinical Areas. Provides Leadership In Meeting Goals And Objectives. Interacts With Managers, Department Heads, Clinical Service Coordinators, And Other Departments In Relation To Projects.
  • 3. Serves As L+M And Wh Liaison For Accrediting, Licensing, And Regulatory Bodies And As An Expert Resource On Accreditation And Regulatory Issues To L+M And Wh And System Staff, Physicians, Lips, And Leadership.
  • 4. Provides Interface And Leadership With Industry Associations (E.G. Tjc, Cha, Jcr, Vizient) To Represent L+M And Wh When Standards Are Being Designed, Developed Or Redesigned And Sharing Of Best Practices.
  • 5. Directs, Oversees, Reviews, Prepare, Reports, Evaluates And Assures Timely Completion Of All Documents Related To Proactive (E. G. Applications, Periodic Performance Review) And Retroactive Requirements Of Accrediting, Licensing And Regulatory Agencies (Cms, Dph, Tjc), Such As; Requirements For Improvement, Comprehensive Corrective Action Plans, And Quality Compliance Monitor Reports.
  • 6. Uses Six Sigma, Cap, Lean, Workout And Other Methodologies To Achieve Performance Improvements And To Enhance Clinical Quality And Patient Safety. Facilitates Integration Of Methodology With Quality Improvement Goals Of The Departments. Provides Key Regulatory, Safety And Quality Data Highlighting Business And Operational Issues Requiring Management Attention And Resources. Participates In Departmental Task Forces And Committees To Provide Operational Input.
  • 7. Provides Leadership, Guidance And Direction To Clinical Department And, As Chair Of Tjc/Regulatory And Other Committees, Leads The Group To Assess All Aspects Of Hospital Tjc/Dph/Cms Readiness. In Conjunction With Staff And Other Hospital Representatives, Directs Tracer Rounds To Assess Compliance With Regulatory Requirements And Prioritize To Remediate To Improve Performance.
  • 8. Serves On Various L+M And Affiliate Committees, Which Will Change As Applicable, Including, Serious Events Review, Quality, Regulatory And Nursing Committees, And Others As Needed, As Well As, Outside Organizational Committees Such As With Connecticut And/Or Rhode Island Hospital Association.
  • 9. Directs Plans, Oversees, Analyzes Data, And Communicates Results For The Performance Of Mock Surveys, Self-Assessments And Consultant Reviews Focused On Continuous Accreditation, Safety And Regulatory Compliance.
  • 10. Collaborates With Information Technology, Quality Improvement, And Other Departments To Explore Databases For Outcomes Measurement And Process Improvement Opportunities.
  • 11. Maintains Professional Growth, Expertise And Development To Keep Up With Changes In The Field, Make Recommendations For Ensuring Accreditation And Licensure Compliance, Education And Implementation Of National Patient Safety Goals And Regulations.
  • 12. Works Collaboratively With The Medical And Operational Directors Of Both The Inpatient And Outpatient Services, And Other Clinical Leaders, To Set Goals/Assess Hospital Performance, Prioritize Resources, Implement Change Through Facilitation And Other Activities, And Assess Project Success.
  • 13. Provides Mentoring, Coaching, And Facilitation Of Skill Development For Direct Report Employees.
  • 14. Creates, Directs, And Supports Development Of Strategic Educational And Training Programs Relating To Compliance Issues, Safety And Continuous Regulatory Compliance.
  • 15. Collaborates With Ynhhs Peers For System-Wide Work On Tjc, Cms, And Dph Accreditation, Licensure, Safety And Regulatory Affairs. Provides Expertise/Teaching For The System?S Institute For Excellence.
  • 16. Manages Departmental Budget To Ensure Fiscal Responsibility And Accountability And Prepares Budgetary Recommendations For The Executive Director, Accreditation & Regulatory Affairs.
  • 17. Performs Other Assignments As Required And/Or Directed By Executive Director, Accreditation & Regulatory Affairs.

    Other information:

    EDUCATION:

    Current Rn Licensure In The State Of Connecticut Or Rhode Island With Degree In Nursing An Mba, Mph, Or Other Masters Degree In Health Care Management Required.

    EXPERIENCE:

    Five (5) To Ten (10) Years Of Progressive Clinical Experience In An Acute Care Hospital With Five (5) Years Of Experience In Process Improvement With Clinical Operations And Experience In High Level Analytical Tools And Project Management, 6-Sigma Or Other Formal Process Improvement Training. Proficient Knowledge And Application Of Joint Commission (Jc), Center For Medicare And Medicaid Services (Cms) And Connecticut Or Rhode Island Department Of Public Health (Dph) Regulations, Standards, Conditions Of Participation (Cop), And Applicable Laws. Experience With Accreditation, Licensure, Adverse Events And Complaints Surveys And Investigational Process Required.


    LICENSURE:

    Ct & Rhode Island Rn Licensure

    SPECIAL_SKILLS:

    ACCOUNTABILITY:

    COMPLEXITY:

    PHYSICAL_DEMAND:

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    Job Info

    Job: 9734

    Department: Accreditation and Reg Affairs
    Category: Mgmt/leadership
    Sub Category: NON-CLINICAL
    Status: Full Time
    Shift: DAYS
    Hours: 40.00

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