Accreditation Program Manager

Hennepin Healthcare•Minneapolis, MN

2d•Onsite

About The Position

We are currently seeking an Accreditation Program Manager to join our Performance Measurement and Improvement team. This full-time role will primarily work on-site (days). Purpose of this position: This position serves as the primary contact and advisor regarding matters related to The Joint Commission (TJC) accreditation and Centers for Medicare and Medicaid Services (CMS) regulations including interpretation and education of new standards, assessment of compliance, identification of opportunities for improvement, and facilitating efforts to achieve and maintain compliance. Responsible to design and direct effective implementation of the compliance plan for the hospital and clinics to ensure survey readiness, in addition to overseeing the organizational policy process.

Requirements

Bachelor’s degree in related healthcare field. Master’s degree preferred
Graduation from an accredited school of nursing preferred
Three (3) years’ experience working with regulatory agencies such as The Joint Commission or CMS on survey preparation
Four (4) years’ experience working in an acute hospital setting
Knowledge of The Joint Commission and CMS regulatory requirements
Analysis, communication, presentation, prioritization, and problem-solving skills
Measurement, data gathering, and interpretation experience
Knowledge of patient care standards
Performance improvement principles and methods experience
Attention to detail and ability to work with complex processes
If incumbent is a Registered Nurse, possession of a valid license, or a permit to practice, issued by the State of Minnesota Board of Nursing is required

Responsibilities

Provides leadership and coordination to achieve compliance with TJC standards and CMS regulations
Advises the senior administrative and physician leaders of emerging needs, critical issues, achievements and changing requirements
Provides recommendations to senior administrative and physician leaders regarding action strategies to achieve or maintain compliance with standards/regulations
Provides on-going review, evaluation, interpretation of standards/regulations, and requirements when there are changes, revisions, and new standards/regulations
Coordinates and monitors compliance related to the implementation of TJC standards and CMS regulations
Serves as the organization’s primary resource and advisor related to TJC accreditation and CMS regulations for other internal and external regulatory agencies
Develops, coordinates, and disseminates information to the Regulatory Steering Committee
Develops systems and structures to support continual readiness
Designs and implements evaluation processes and tools to assess the level of compliance with TJC standards and CMS regulations
Designs and implements reporting processes to assure that leaders have the information they need to improve performance for areas of non-compliance
Directs activities designed to improve performance in areas of significant need across the organization
Develops and implements strategies to various organizational committees to communicate assessment findings and report progress, barriers, and successes
Develops process to manage implementation of required requirements such as policies, procedures, standard work, and/ or reports
Assesses systems for data collection and analysis of regulatory standards information and provides recommendations for improvement
Assists in developing data collection systems to ensure performance measures are tracked and trended for identified improvement strategies
Manages assigned staff, facilitates standard work and coaching/developing of staff
Provides oversight and direction for the Accreditation Program Specialist(s)to implement standard work
Provides direction for ongoing activities for regulatory survey readiness
Guides workflows to ensure effective outcomes for regulatory compliance
Support activities for team members to participate in educational development for regulatory compliance
Coordinates TJC survey and CMS/Minnesota Department of Health (MDH) survey activities
Serves as key contact with TJC for all survey preparations and on-site activities
Serves as the key contact for all CMS/MDH survey onsite-activities
Coordinates all on-site survey preparations including identifying survey participants, scheduling, logistics, and survey accommodations
Coordinates all required follow-up and formal responses related to findings
Provides and coordinates implementation of education, training, and consultation in relation to identified learning needs
Conducts a needs assessment for various individuals, teams and committees regarding the understanding and interpretation of TJC standards and CMS regulations
Develops educational methods and tools to meet the defined learning needs across the organization
Develops and implements communication mechanisms to support continual survey readiness activities; communicates assessment findings and celebrates successes
Stays current with TJC standards, CMS regulations and survey methods
Maintains current expertise in all aspects of TJC accreditation and CMS regulations
Networks with other hospitals locally and nationally to build understanding of standards and identify best practices
Maintains current knowledge of other regulatory agencies including OSHA, Life Safety Code, EMTLA, HIPAA, etc
Facilitates and/or participates in various teams and committees as appropriate to support specific improvement efforts and continual readiness
Participates in the standardization of policy development and approval processes throughout the organization
Participates on appropriate teams in which expertise of TJC standards and CMS regulations are required
Facilitates process improvement teams as needed
Works collaboratively with other departments and functions to develop an integrated approach to patient safety
Participates in the organizational policy review process through the Accreditation chapter structure
Serve as Policy Committee member and supports process for review of all policies at least every four years
Reviews policies as a key stakeholder to provide feedback regarding standards interpretation
Participates in the approval process with new, revised or achieved policies