Howard University Hospital | Washington, DC

    Regulatory Accreditation Program Manager

    Job Title
    Regulatory Accreditation Program Manager
    Job ID
    27583181
    Location
    Washington,  DC 20060
    Other Location
    Description

    POSITION SUMMARY:

    Coordinates quality assurance activities for a Howard University Hospital (HUH) through continuous improvement of quality patient care. Develops and implements organizational initiatives to support accreditation and regulatory continuous readiness through Standards interpretation, Standards compliance, Education and communication, and Survey operations. Promotes a continuous readiness program that emphasizes quality and patient safety at the forefront of regulatory compliance. Oversees the day-to-day program operations and workflow.

    NATURE AND SCOPE:

    Interacts with Quality Staff, Chief Medical Officer, physicians, nurses, other healthcare providers and Hospital and University officials.

    PRINCIPAL ACCOUNTABILITIES: 

    • Collects, analyzes, and reports data measuring the quality of patient care.  Identifies regulatory vulnerabilities and collaborates with hospital departments to identify and implement corrective action for underperforming areas or functions
    • Proactively leads the ongoing evaluation, planning and support of the continuous readiness infrastructure and processes to ensure Joint Commission accreditation and other regulatory accreditation, certifications, and applicable organizational licenses
    • Provides guidance on Joint Commission standards, CMS COP’s interpretation and other regulatory requirements as they apply to organizational practice.
    • Tracks and maintains The Joint Commission accreditation plan.  Develops and implements initiatives to evaluate and monitor compliance with Joint Commission and other regulatory standards through ongoing, organizational assessment, i.e. Intracycle Monitoring, Focused Standards Assessment, tracers, mock surveys and measurement data
    • Serves as contact and point person for Joint Commission accreditation manuals, standards-related publications and newsletters and educational materials; ensures pertinent information is communicated to appropriate individuals
    • Finalizes and submits corrective action responses to The Joint Commission and other regulatory agencies for survey and for-cause and compliant investigations.
    • Collaborates with content experts and executive sponsors to ensure corrective action plans are implemented, measures are in place and monitored to sustain accreditation
    • Oversees organizational wide announcements and communications related to onsite surveys including the initial announcements, daily updates, and concluding remarks.  Manages onsite accreditation and regulatory surveys; directs command center activities.  Manages communications, agendas, and logistics for onsite survey activities.  Services as liaison between onsite surveyors and organization
    • Leads organization-wide accreditation and regulatory compliance initiatives. Develops education and reference materials and delivers quality-related training sessions

    ORGANIZATIONAL EXPECTATIONS:

    • Promotes adherence to the Health Sciences Compliance Program, the Howard University Code of Ethics, the Health Sciences Standards of Conduct and Health Insurance Portability and Accountability Act (HIPAA).
    • Attends annual and periodic mandatory Compliance Program training including the Health Insurance Portability and Accountability Act (HIPAA) Privacy training.
    • Participates in activities that promote adherence to federal healthcare program requirements.
    • Actively participates in Health Sciences Compliance Program activities.
    • Maintains confidentiality of patients, families, and staff. 

    CORE COMPETENCIES:

    • Ability to communicate effectively and professionally with providers, patients and staff
    • Expert knowledge of TJC Standards and regulatory compliance principles, practices and skills, as well as performance improvement principles
    • Demonstrated experience applying quality management/performance improvement and customer service approaches and the ability to function independently
    • Demonstrated experience in using good judgment in working with diverse populations.
    • Demonstrated ability to prioritize activities
    • Strategic vision and agility-ability to think strategically, anticipate future consequences and trends, and incorporate them into the organizational plan
    • Strong organizational, problem-solving and follow-through skills
    • Ability to multi-task constantly, react to changes quickly/productively, and tolerate interruptions
    • Ability to remain flexible, organized, professional and able to analyze, make sound decisions under stressful situations

    MINIMUM REQUIREMENTS:

    • Bachelor's degree in Nursing (preferred) or a related field, or equivalent combination of experience and education.
    • Minimum of 3-5 years' accreditation experience working in the healthcare industry. Prior leadership training, classes or experience.
    • Leadership skills Knowledge of TJC Standards and regulatory compliance issues.
    • Experience applying quality management/performance improvement and customer service approaches
    • Excellent verbal and written communication skills. 

     

    At Howard University Hospital our job is to care for you. We do this by offering:

    Work-life balance
    Recognition and rewards for professional expertise
    Competitive, comprehensive benefit plans offered (including health, disability, vacation, sick leave, and 403B retirement plan)

    COVID-19 Vaccination  

    Howard University Hospital requires all external applicants to be fully vaccinated for COVID-19 before commencing employment.  External Applicants may be required to furnish proof of vaccination and, if offered, may elect to be vaccinated at a designated Howard University Hospital location. 

    Required Skills

    Bachelor's degree in Nursing or a related field, or equivalent combination of experience and education.
    Registered Nurse
    Minimum of 3-5 years' accreditation experience working in the healthcare industry. Prior leadership training, classes or experience.
    Leadership skills Knowledge of TJC Standards and regulatory compliance issues.
    Experience applying quality management/performance improvement and customer service approaches
    Excellent verbal and written communication skills.

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