Director, Accreditation, Regulatory and Clinical

Company Description

Located in Largo in the heart of Prince George’s County, our new state-of-the-art regional medical center (UM Capital Region Medical Center) will provide improved access to primary and ambulatory care services and serve as a tertiary care center for critically ill patients. In addition, our new space will allow us to expand our offerings as a community partner to help improve the health status of Prince George’s County residents.

Job Description

The Director of Accreditation is responsible for establishing and maintaining a continuous survey readiness culture for Prince George’s Hospital Center, Bowie Health Center, Outpatient Centers and Laurel Regional Hospital. Primary duties include educating, monitoring and identifying areas of opportunity to insure standards for the Joint Commission, Department of Health & Mental Hygiene, and Centers for Medicare & Medicaid Services, commission for the Accreditation of Rehabilitation Services, as well as other regulatory institutions as necessary. Achievement of positive survey outcomes and a safe patient environment is the primary goal for the Director of Accreditation. This position reports to the UMCAP Senior Director of Clinical Quality & Patient Safety. Also acts at the primary liaison for The Joint Commission (TJC).

Principal Duties:

1. Assume management responsibility over all accreditation and regulatory functions ensuring efficiency and compliance.

2. Serve as expert resource on accreditation and regulatory issues for UMCAP staff, physicians and leadership.

3. Provide leadership in the development and implementation of strategies regarding education of the regulatory standards and update education as standards change.

4. Maintain current awareness of state, federal and national regulations required to maintain accreditation and/or certification for all areas of UMCAP.

5. Coordinate and facilitate the Continuous Survey Readiness Committee and ensure Chapter Captains are current on all requirements.

6. Identify areas in which the organization(s) do not meet the intent of the standards. Coordinate work groups and/or performance improvement activity to bring the standard in line with the regulations.

7. Collaborate with supervisor & UMCAP leadership to address areas of opportunity, identify strategies to improve performance, implement and evaluate corrective actions.

8. Plan and oversee mock surveys and associated action plans.

9. Ensure timely completion and oversee the completion of ongoing self-assessments for standard compliance for the annual TJC Periodic Performance Review and Measures of Success.

10. Prepare reports and evaluate progress regarding status of compliance for improvements and deficiencies identified by regulatory deficiencies.

11. Responsible for regulatory complaint surveys and follow up.

12. Submit timely reports to the regulatory entities related to action plans as well as follow up for areas in need of improvement.

13. Serve as the system representative for external interaction with accreditation and regulatory entities

14. Develop strategies to enhance compliance.

15. Perform other duties as assigned by the supervisor.

Customer Service:

1. Greets customers in courteous, friendly, respectful and professional manner at all times, including maintaining eye contact when appropriate.

2. Follows communication protocols to both internal and external customers, including introducing him/herself with job title and experience, asking open ended questions, such as “How may I be of help to you?” using the customer’s name as soon as it is learned.

3. Responds promptly and appropriately to customer questions/concerns/complaints and attempts immediate resolution.

4. Keeps customer’s information confidential, including public places such as elevators or the cafeteria.

5. Provides assistance and offers help immediately, including finding someone else to meet the request, if unable to do so him/herself. Introduce other staff to customers when a hand-off occurs and explain that the person will provide excellent service.

6. Demonstrates commitment to excellent service recovery when a customer’s expectations have not been met.

Commitment to Co-Workers:

1. Offers assistance to colleagues and other departments when needed.

2. Takes responsibility for solving problems regardless of origin; completes assignments, and respects deadlines.

3. Resolves conflict directly with colleagues and seeks assistance from others if the issue cannot be resolved. Refrains from criticism in public.

4. Mindful and respectful of others’ time and schedules. Attends meetings on time and communicates any absences.

5. Provides co-workers with a status report for continuity of workflow when planning to be out of the office, off the unit, or away from the de