Sr Director Regulatory Accreditation Compliance Administrator

ScionHealth•Louisville, KY

About The Position

At ScionHealth , we empower our caregivers to do what they do best. We value every voice by caring deeply for every patient and each other. We show courage by running toward the challenge and we lean into new ideas by embracing curiosity and question asking. Together, we create our culture by living our values in our day-to-day interactions with our patients and teammates. Job Summary Provides oversight of Survey Readiness Assessment (SRA) Team who is responsible for development, support, training and fostering expertise in Survey Management by leveraging subject matter expertise in key clinical areas to support hospital survey readiness and high reliability principles. Under the direction of the VP Quality Systems and Accreditation and in collaboration with Division Management and hospital executive teams, develops strategies and deploys tactics that promote clinical excellence, safety and regulatory readiness to achieve the mission, vision and goals established by Scion Healthcare. Provides support and leadership of the SRA Team to collaborate with facilities to implement established standards of care and high reliability practices. Essential Functions Functions as lead of SRA Team for development and coordination of tactics to meet key team objectives: Ongoing proactive survey readiness and survey response support. Provides subject matter expertise in conducting Survey Readiness Assessments (SRA) for ScionHealth facilities in preparation for TJC triennial and CMS surveys. Provides education, training and functions as a resource for SRA Team, Support Center, Division/District and facility staff in specific areas that include clinical subject matter expertise relating to survey readiness and management. Functions as subject matter expert in oversight, writing and completion of Plans of Correction (POC) in response to results of TJC and CMS surveys. Guides hospitals in follow through and sustainment of POC, despite whether that POC is a result of internal or external survey. Teaches hospital leaders how to prioritize survey findings to those that are critical to patient safety and future survey compliance. Collaborates with facility-level leadership on all aspects of survey management; from the time the exit conference is conducted to the clearance of high risk survey findings, including the writing of a plan of correction in response to a statement of deficiences. Maintains survey tracker and archiving survey documents for ScionHealth. Regularly audits thoroughness and effectiveness of documentation as a way to evaluate proactive survey compliant practices. Monitors standards of care opportunities identified during survey readiness assessment, works with clinical operations team and hospital leadership to create output from these learnings, including, for example, updated policy and guidance statements, education materials, training sessions, etc. Assesses high reliability practices through on-site surveys and review of outcomes; provides education/support to facilities in their journey to reduce harm and foster high reliability. Completes special project requests timely as directed by the VP Quality Systems and Accreditation Compliance in collaboration with Vice President of Clinical Operations to accomplish Division/District needs. Evaluates performance of SRA Team members and provides feedback and coaching. Supports SRA Team members in professional development plans. Ensures fiscal responsibilities and judicial use of resources in coordinating Knowledge/Skills/Abilities/Expectations Excellent organizational skills. Strong team-oriented approach. Excellent conflict resolution skills. Excellent investigative skills. Strong knowledge of regulatory requirements for healthcare. Work independently with minimum supervision. Excellent oral and written communication and interpersonal skills. Ability to work under stress and in emergency situations. Strong knowledge of Microsoft Office Suite products; especially word processing and spreadsheet software. Ability to be flexible in use of all forms of medical records (paper and electronic). Must read, write and speak fluent English. Approximate percentage of time required to travel: 75% Performs other related duties as assigned.

Requirements

Excellent organizational skills.
Strong team-oriented approach.
Excellent conflict resolution skills.
Excellent investigative skills.
Strong knowledge of regulatory requirements for healthcare.
Work independently with minimum supervision.
Excellent oral and written communication and interpersonal skills.
Ability to work under stress and in emergency situations.
Strong knowledge of Microsoft Office Suite products; especially word processing and spreadsheet software.
Ability to be flexible in use of all forms of medical records (paper and electronic).
Must read, write and speak fluent English.
Bachelor's degree in nursing required
Master's degree in Healthcare related field required.
Registered Nurse required
Minimum five years' experience in clinical management and leadership positions.

Nice To Haves

CPPS preferred
Experience in hospital setting with multi-facility responsibilities and nurse executive experience, including participation in regulatory management preferred.
Subject matter expertise in ICU, cardiac, Med/Surg, Peri-operative, Maternal-child, Infection Control, Emergency or Radiology product lines preferred

Responsibilities

Functions as lead of SRA Team for development and coordination of tactics to meet key team objectives: Ongoing proactive survey readiness and survey response support.
Provides subject matter expertise in conducting Survey Readiness Assessments (SRA) for ScionHealth facilities in preparation for TJC triennial and CMS surveys.
Provides education, training and functions as a resource for SRA Team, Support Center, Division/District and facility staff in specific areas that include clinical subject matter expertise relating to survey readiness and management.
Functions as subject matter expert in oversight, writing and completion of Plans of Correction (POC) in response to results of TJC and CMS surveys.
Guides hospitals in follow through and sustainment of POC, despite whether that POC is a result of internal or external survey.
Teaches hospital leaders how to prioritize survey findings to those that are critical to patient safety and future survey compliance.
Collaborates with facility-level leadership on all aspects of survey management; from the time the exit conference is conducted to the clearance of high risk survey findings, including the writing of a plan of correction in response to a statement of deficiences.
Maintains survey tracker and archiving survey documents for ScionHealth.
Regularly audits thoroughness and effectiveness of documentation as a way to evaluate proactive survey compliant practices.
Monitors standards of care opportunities identified during survey readiness assessment, works with clinical operations team and hospital leadership to create output from these learnings, including, for example, updated policy and guidance statements, education materials, training sessions, etc.
Assesses high reliability practices through on-site surveys and review of outcomes; provides education/support to facilities in their journey to reduce harm and foster high reliability.
Completes special project requests timely as directed by the VP Quality Systems and Accreditation Compliance in collaboration with Vice President of Clinical Operations to accomplish Division/District needs.
Evaluates performance of SRA Team members and provides feedback and coaching.
Supports SRA Team members in professional development plans.
Ensures fiscal responsibilities and judicial use of resources in coordinating
Performs other related duties as assigned.