Under the direction of the Director of Patient Safety, Risk Management and Quality, and working collaboratively, the Accreditation & Regulatory Manager leads efforts to ensure continual organizational compliance and ongoing readiness with clinical quality and patient safety standards and regulations required by The Joint Commission, Massachusetts Department of Public Health and Center for Medicare and Medicaid Services. In this role the Accreditation & Regulatory Manager proactively plans, implements, coordinates and continually improves the Boston Medical Center's (BMC) efforts related to compliance, accreditation, and licensure requirements.
ESSENTIAL RESPONSIBILITIES / DUTIES:
Serves as the organizational expert for The Joint Commission, DPH and CMS standards, regulations and conditions of participation.
Responsible for the interpretation and communication of regulatory and licensing requirements throughout the organization.
Provides education and consultation to administrative and clinical leadership, staff and faculty throughout BMC regarding the requirements of accreditation and regulatory organizations, using both formal and informal venues, e.g. presentations, publications, email, computer-based methods.
Provides guidance and assistance to departments, sections, units and programs regarding improvements needed to ensure compliance with requirements of TJC, DPH and CMS.
Provides informal consultation and advice to assist administrative and clinical leaders and their departments in improving performance.
Builds effective, supportive, productive relationships with leadership, staff and faculty throughout BMC.
Facilitates development of tools, policies, and procedures, and learning aids to promote compliance with standards.
Provides timely communication regarding new and revised TJC, CMS, DPH standards and interpretations to administrative and clinical leadership, staff and faculty.
Works closely and builds effective working relationships with accreditation and regulatory agencies, i.e., The Joint Commission, DPH and CMS.
Responsible for all aspects of the plan to ensure continual readiness with the clinical regulatory and accreditation requirements of the TJC, DPH and CMS. This includes but is not limited to:
- Development, coordination, and implementation of the continual readiness plan
- Ongoing assessment of the continual readiness plan; identification of needed improvements; and preparation and implementation of plans to achieve needed improvements
- Organizational, department, section, unit and program assessments and identification of risk
- Plan and scheduling readiness mock surveys
- All ongoing communication with regulatory agencies regarding survey and readiness activities
- Completion of annual TJC application
- Periodic Performance Review completion and submission
- Development of remedial action plans
- Responding to agency requests for revision and corrective action plans
Responsible for communication of the continuous readiness plan to leadership and key groups throughout BMC.
Responsible for ensuring preparation of reports assessing institutional, department, section, program and unit compliance with accreditation and regulatory requirements.
Ensure that administrative and clinical leadership are continuously aware of BMC readiness for TJC, DPH and CMS surveys, including description of specific issues that are in need of improvement.
Works closely with Patient Safety/Risk Management, Quality Improvement and Clinical Analytics including coordination of the Joint Commission Performance Improvement and NPSG standards compliance.
Leads a coordinated response to unannounced external accrediting or regulatory agency visits such as DPH, Joint Commission or CMS.
Co-chairs TJC Steering Committee with Director Quality and Patient Safety.
Responsible for overseeing the BMC policy and procedure system including co-chair of the Policy and Procedure Roundtable.
Serves as a member of the Quality and Patient Safety Council and other committees as deemed appropriate.
Works with Patient Safety Risk Management on an as-need basis to support BORM and DPH requirements regarding reporting of adverse events.
Other duties as directed, including the occasional work with non-clinical regulatory agencies such as OSHA.
Baccalaureate Degree in nursing required.
Master's Degree (or equivalent) is also required. Healthcare focus highly desirable.
CERTIFICATES, LICENSES, REGISTRATIONS REQUIRED:
5 years of experience with The Joint Commission, DPH and other regulatory requirements and survey processes.
KNOWLEDGE AND SKILLS:
- Outstanding team player.
- Ability to develop effective relationships with a broad array of people from diverse backgrounds.
- Strong interpersonal skills; ability to establish supportive, collegial relationships.
- Superior organizational skills to manage a large volume of incoming data, information, reports, etc. in paper and electronic formats.
- Ability to create and deliver appealing and compelling presentations to a variety of audiences including clinicians, staff, faculty, administration and governance groups.
- Excellent written and verbal communication skills.
- Demonstrated skill in change management and quality improvement.
- Knowledge of clinical terminology.
- Strong computer skills including Microsoft Office platform—Word, Access, Excel, E-mail. Web/Internet.
- Ability to learn and effectively use computer software, such as electronic health records and data entry.
- Excellent English communication skills (oral and written).
Req ID: 14507Apply Back to Top