Accred/Regulatory Program Manager

At Duke Health, we're driven by a commitment to compassionate care that changes the lives of patients, their loved ones, and the greater community. No matter where your talents lie, join us and discover how we can advance health together.

 

Duke Health Lake Norman Hospital

Pursue your passion for caring with Duke Health Lake Norman Hospital in Mooresville, North Carolina. The smallest of Duke Health’s four hospitals at 123-beds, it offers a comprehensive range of medical services, including 24-hour emergency care, cardiology, orthopedics, women's services, and surgical specialties.

 

General Description of the Job Class

 

The Accreditation and Regulatory Program Manager position is responsible for collaborating, at a system/entity level, with leadership, staff and medical staff to provide a proactive, global and unified perspective and understanding of accreditation, regulatory and disease specific certification requirements and activities. The Accreditation and Regulatory Program Manager, is a systems thinker playing a pivotal role in leading system/entity efforts to achieve the highest compliance with accreditation and certification standards with an approach to ensuring practices not only meet but exceed benchmarks for patient care excellence. This role collaborates in shaping and supporting the framework for ongoing accreditation success, by leveraging extensive knowledge in regulations, standards and improvement methodologies. The position serves the system/entity organization as a resource, mentor, and educator for regulatory, accreditation and certification programs; working across the organization to assess, measure, and report ongoing compliance with standards, promote evidence-based best practices, and standardize common survey processes. The Accreditation and Regulatory Program Manager collaborates with system/entity operational, executive and medical staff leadership to operationalize an effective continuous readiness infrastructure that ensures and sustains the DUHS Accreditation and Regulatory Program goals of 1) Standard interpretation, 2) Standard compliance, 3) Education and communication, and 4) Survey operations. This role includes programmatic ownership of Accreditation and Regulatory activities, ensuring strategic alignment and execution of related initiatives.

 

Duties and Responsibilities of this Level

 

Lead continuous readiness efforts:

Proactively leads the ongoing evaluation, planning and support of the continuous compliance and readiness infrastructure and processes to ensure accreditation by deemed status organizations as well as other regulatory accreditation, certifications and applicable organizational licenses.

Supports workflow needs and develop strengths of content experts and leadership to support workflows.

Collaborate with Patient Safety, Quality, Professional Practice, Risk Management, Legal and other departments to ensure regulatory functions are assessed and in compliance with standards.

In partnership with system/entity leadership identifies accreditation or regulatory risks or vulnerabilities and supports operational leaders in the development, implementation and monitoring of regulatory improvement processes.

Directly leads and manages system/entity-wide accreditation and regulatory compliance initiatives, tracking and monitoring corrective actions.

Co-leads with operations, system/entity-wide accreditation and regulatory compliance initiatives and tracks and monitors corrective actions.

Provides guidance on accrediting and certification standards interpretation and other regulatory requirements as they apply to clinical practice.

In partnership with system/entity leadership, establishes processes to conduct ongoing proactive review of regulatory, accreditation and certification standards.

Develops and implements initiatives to evaluate and monitor compliance with regulatory standards through ongoing organizational assessment (Intracycle monitoring, Focused Standards Assessment, tracers, mock surveys and measurement data).

Supports and participates, as requested, in entity pre-survey, on-site survey and post-survey activities for accreditation, regulatory and certification programs.

Co-ordinates and participates in system/entity internal surveys using process audit tools and techniques to assess and evaluate ongoing survey readiness.

Participation in the development, review and evaluation of ongoing system/entity regulatory and accreditation program that promotes continual improvement of compliance with standard requirements. Serves as an expert in identifying high risk and patient safety sensitive processes and ensures activities are in place for ongoing risk assessment.

Conducts ongoing monitoring, measurement and analysis of survey data and trends, communicates aggregat