Works under the direction and supervision of the Director of Accreditation. Responsible for managing, coordinating and implementing components of the Accreditation program for the organization systemwide. Responsible for managing and facilitating Det Norkse Veritas DNV and other accreditation/regulatory related workgroups as assigned. Provides assistance, direction, education, and support throughout the organization relating to accreditation/regulatory requirements. Serves as a liaison between the medical center or its affiliated healthcare entities, and accreditation and regulatory agencies. Assists with preparing responses to regulatory and accreditation agencies, such as, Centers for Medicare and Medicaid Services (CMS), Department of Health Service Regulation (DHSR), Det Norkse Veritas (DNV), and other agencies as required. Assumes additional responsibilities as requested or in the absence of the Director of Accreditation.
1.In collaboration with the Director of Accreditation, manages, coordinates and implements, components of the Accreditation sustainability program (such as, Accreditation Talking Points, Accreditation Readiness Team (ART), Medical Record Tracers Team, Leadership Tracer Rounds, Zero Defect Rounds).
2.In collaboration with the Director of Accreditation participates in accreditation and regulatory surveys.
3.In collaboration with the Director of Accreditation, develops responses and action plans accreditation and regulatory compliance issues related to DNV, DHSR, CMS and others as required.
4.Coordinates and facilitates completion of workplans and action plans regarding new regulations or areas identified for improvement.
5.Facilitates DNV preparation by validating standards, conducting rounds, coordinating interviews, reviewing policies and procedures.
6.Participates in survey activities and manages action plans and responding to survey findings under the direction of the Director of Accreditation.
7.Collaborates with leaders and staff to assess compliance with accreditation and regulatory requirements and problem solve areas that require improvements.
8.Maintains ongoing knowledge and awareness of accreditation and regulatory requirements.
9.Develops written education materials about accreditation and regulatory issues, and conducts education as necessary.
10.Is a knowledge resource and provides on-going education to management and staff regarding accreditation and regulatory requirements.
11.Develops, initiates, revises, and maintains organization-wide and department level policies and procedures related to accreditation and regulatory requirements.
12.Establishes positive relationships, communication, and follow-up with Leadership, Medical Staff and all areas of personnel.
