Manager Accreditation and Reg Affairs

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Bridgeport, CT
Oct 14, 2019


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.

Directly reports to the Executive Director, Accreditation & Regulatory Affairs, YNHHS and works collaboratively with members of Senior Operations Group, Management teams, and Medical staff leadership. Has responsibility and accountability to provide direction, planning, oversight and consultation to ensure hospital Accreditation, Licensing, and Regulatory mandates are met (e.g. CMS, DPH, TJC) at assigned Delivery Networks. In conjunction with the Executive Director, Accreditation & Regulatory Affairs, YNHHS, works to improve key processes, policies and procedures as they relate to accreditation 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. Works as an internal consultant with medical staff, nursing, support services, and other departments to direct, plan, organize, facilitate, and evaluate Assigned Delivery Networks efforts to improve process efficiencies, assess regulatory compliance and improve overall patient safety and clinical quality. Provides project management expertise necessary to drive significant breakthroughs. Responsible for independent action in project oversight, systems design and implementation, quality improvement and a variety of special projects. Uses Six Sigma, LEAN, change management and acceleration (e.g., CAP, Workout), and/or other available performance improvement methodologies to achieve these goals. In conjunction with the Legal Office, the Hospital Safety Committee, Laboratory Medicine and Performance Management colleagues, works to assess the impact of quality projects on clinical operations as well as gauge readiness for internal and external surveys by CMS, DPH, TJC, and others as needed. This position has overall responsibility and oversight for site visit preparation, coordination of site visit logistics and response, as well as collaborating with Executive Director, Accreditation & Regulatory Affairs, YNHHS, major regulatory changes and issues and mock or real survey results. This position collaborates with YNHHS peers for system-wide work, education and sharing of best practices related to accreditation, licensure, and regulatory affairs. The position manages the staff and budget for regulatory affairs and direct reports at assigned Delivery Networks. It also provides facilitation and mentoring for daily operations, skill acquisition and performance for direct reports.



  • 1. Consults routinely with executives, corporate legal counsel, risk management, and/or operations managers 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 Assigned Delivery Networks liaison for accrediting, licensing, and regulatory bodies and as an expert resource on accreditation and regulatory issues to Assigned Delivery Networks and System staff, physicians, LIPs, and leadership.
  • 4. Provides interface and leadership with industry associations (eg. TJC, CHA, JCR, Vizient) to represent Assigned Delivery Networks 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 departments 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 YNHHS 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, Operations 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 YNHHS Institute for Excellence.
  • 16. Manages departmental budget to ensure fiscal responsibility and accountability and prepares budgetary recommendations for the Executive Director, Accreditation & Regulatory Affairs, YNHHS.
  • 17. Performs other assignments as required and/or directed by Executive Director, Accreditation & Regulatory Affairs, YNHHS.
  • 18. Facilitates system standardization of hospital accreditation, licensure, CMS certification, activities, systems, and processes.



Bachelor's degree in Nursing and an MBA, MPH, or other Masters degree in health care management required.


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 processes required.


Current RN licensure in the state of Connecticut or Rhode Island


Proven analytical/problem-solving and decision making skills and ability to work autonomously and self directed in the management of programs and projects and to work collaboratively with teams is required. Outstanding communication, presentation and facilitation skills are necessary. Strong computer skills (e.g., Microsoft PP and Excel) and demonstrated ability to successfully lead process change are needed. Strong management skills and very strong planning skills are required. Knowledge and experience of CAP, Workout and LEAN, DMAIC preferred. Demonstrated ability to lead diverse groups of employees and medical staff in accreditation, safety and regulatory affairs is essential. Strong healthcare clinical background essential with inpatient hospital experience required.


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Job Info

Job: 11981

Department: Accreditation and Reg Affairs
Sub Category: 1ST LEVEL MGR (MGR/SUP)
Status: Full Time Benefits Eligible
Shift: D
Hours: 40

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