Manager of Accreditation and Regulatory Readiness

Brown Medicine

4d • Onsite

About The Position

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. KEY ACCOUNTABILITIES: Consistently applies and serves as a role model for the Brown University Health shared “CARE” values of Compassion, Accountability, Respect and Excellence. Is responsible for knowing and acting in accordance with the principles of the Brown University Health Corporate Compliance Program and Code of Conduct. 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

Requirements

• A bachelor’s degree in health administration, nursing or healthcare professional field is required.
• 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.
• 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.

Nice To Haves

• Advanced degree in related field preferred.
• Experience with the principles and practices of healthcare quality management preferred.

Responsibilities

• 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.

What This Job Offers

• Job Type: Full-time
• Career Level: Manager
• Number of Employees: 251-500 employees