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Regional Director of Regulatory and Accreditation

Company: Skagit Valley Hospital
Location: Mount Vernon
Posted on: April 5, 2021

Job Description:

Position Regional Director of Regulatory and Accreditation Req Code 19476 Location Skagit Valley Hospital Job Summary The Regional Director of Regulatory and Accreditation is dedicated to promoting a culture of regulatory compliance throughout Skagit Regional Health. As the ISO Management Representative, this role chairs the Clinical Quality & Standards Committee, ensuring that processes needed for the quality management system are established, implemented and maintained. This team member regularly reports to senior management on the performance of the quality management system and any need for improvement, ensuring the promotion of awareness of customer requirements throughout the organization. The Regional Director assures accreditation preparedness; oversees all mandatory requirements and recommends actions to improve those measures. Essential Functions This role leads the accreditation preparedness and coordinates the internal auditing process. Conducts ongoing assessments of accreditation readiness and assures actions are implemented to maintain compliance. Organizes, analyzes and trends Quality Program outcomes to meet regulatory standards. Oversees all mandatory regulatory reporting requirements and recommends actions to improve quality measures and uses data-driven focus to set priorities for improvements aligned to the strategic plan. Receives, analyzes and distributes DNV, CMS, Qualis, State and regulatory quality program materials. Oversees the management and reporting of Leapfrog. Participates in multi-disciplinary hazard rounds. Communicates Quality Program goals and outcomes to the organization in creative and varied methods and forums. Plans and evaluates multidisciplinary, process improvements relating to quality of clinical care. Recommends policy and procedure changes to improve care and patient outcomes using clinical knowledge base. Attends Quality Program meetings and stays informed of Quality Program changes and progress. Serves as a resource to work groups to help identify, plan and trend quality projects. Is knowledgeable of PDSA, CQI and SPC controls, and education methods. Works with the Executive leadership team to manage risk in the organization as related to quality issues.Leads and/or participates in developing and designing systems and processes for the new organization. Continually improves and redesigns processes to increase productivity and quality.Collaborates with leaders to ensure the organization and departments are fiscally responsible, this includes review of VBP and eCQM measures and corporate billing compliance. Adheres to all SRH policies and procedures. Performs other duties as assigned. Education BSN/BS/BA or Degree in health care related field or business administration with equivalent workexperience is required. Master's Degree in public health, other healthcare related field or business administration, or equivalent work experience preferred. Experience/Training Requires a minimum of 5 years of clinical and/or regulatory compliance experience required. Experience with DNV accreditation and ISO 9001 standards highly desired. License/Certification Joint Commission Professional (CJCP) Certification or DNV GL Certification required within 18 months of hire. Certification in Healthcare Quality (CPHQ) required within 18 months of hire. Current and unrestricted Washington State clinical licensure required, Registered Nurse license preferred. Other Qualifications Hands - on clinical experience and experience in quality improvement and process improvement, required. Experience with integrated healthcare delivery systems experience or demonstrated knowledge of hospital and clinic practice standards needed. Demonstrated experience with data management and a facility with statistical analysis, data collection tools and regulatory standards required. Exceptional leadership skills are needed to include the ability to manage change. The ability to develop and follow a budget needed. Lean or other process improvement experience preferred. Ability to work independently and with small and large groups of healthcare professionals, providers, and others in the organization to problem solve, set priorities, plan and schedule workload to meet deadlines. Ability to display data graphically and must be able tocommunicate effectively in both oral and written form. Experience with DNV accreditation and ISO 9000 Standards highly desired.

Keywords: Skagit Valley Hospital, Mount Vernon , Regional Director of Regulatory and Accreditation, Executive , Mount Vernon, New York

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