Director of Quality, Regulatory Affairs and Accreditation

Job Summary

Under the direction of the Chief Quality Officer, directs the strategic management and planning for Joint Commission Accreditation and accreditation related activities for all clinical services throughout the health system, including hospitals, clinics, behavioral health centers and ambulatory surgery centers.

Sets guidelines to meet requirements for Joint Commission Accreditation leading to successful accreditation for all entities within the health system.

Develops and maintains a comprehensive accreditation project plan adhering to standards, prioritized interventions and on-going monitoring for compliance as established by Joint Commission for all accreditation requirements.

Develops and manages a plan to assure compliance with Centers for Medicare and Medicaid Services (CMS) Conditions of Participation.

Coordinates efforts to earn outstanding clinical performance and a positive customer experience as required for accreditation.

Coordinates efforts to assure regulatory compliance with standards established by our managed care partners.

General Administrative Responsibilities

Collective Bargaining

• Review applicable Collective Bargaining Agreements and consult with Labor Relations to generate management proposals
• Participate in collective bargaining negotiations, caucus discussions and working meetings

Discipline

• Document, recommend and effectuate discipline at all levels
• Work closely with labor relations and / or labor counsel to effectuate and enforce applicable Collective Bargaining Agreements
• Initiate, authorize and complete disciplinary action pursuant to CCH system rules, policies, procedures and provision of applicable collective bargaining agreements

Supervision

• Direct and effectuate CCH management policies and practices
• Access and proficiently navigate CCH records system to obtain and review information necessary to execute provisions of applicable collective bargaining agreements

Management

• Contribute to the management of CCH staff and CCH’ systemic development and success
• Discuss and develop CCH system policy and procedure

General Administrative Responsibilities continued

Consistently use independent judgment to identify operational staffing issues and needs and perform the following functions as necessary;

hire, transfer, suspend, layoff, recall, promote, discharge, assign, direct or discipline employees pursuant to applicable Collective Bargaining Agreements

Work with Labor Relations to discern past practice when necessary

Typical Duties

• Establishes guidelines to meet Joint Commission accreditation requirements
• Develops and leads a regulatory survey readiness program in support of the organization's mission, values and business objectives
• Develops and maintains a comprehensive project plan linked to standards with on-going monitoring and reporting to senior management
• Serves as the System's resource in questions related to accreditation and to CMS standards
• Works with CCHHS senior management and clinical staff in leading and managing all aspects of the accreditation process and standard adherence
• Coordinates activities with subject matter experts and unit business owners
• Conducts training and coaching to support understanding of accreditation standards and requirements
• Develops and maintains plans to assure compliance with regulatory requirements of managed care plans
• Develops and manages audit activities to ensure compliance with accreditation standards and develops and maintains a dashboard to demonstrate ongoing compliance
• Facilitates communication of information among governance committees and serves as liaison on accreditation issues and changing standards
• Maintains accreditation and audit document library
• Maintains and updates policy library
• Performs other duties as they might be assigned

Reporting Relationship

Reports to the Chief Quality Officer

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Minimum Qualifications

• Bachelor's degree from a four-year accredited university
• Successful completion of the accreditation process resulting in a fully accredited designation
• Five (5) years of experience in management or leadership role within a large hospital or healthcare system
• Seven (7) years of experience with accreditation and regulatory survey process, development and follow-up of corrective plans
• Proficiency using Microsoft Office (Outlook, Excel, Word, and PowerPoint)

Preferred Qualifications

• Five (5) years of experience in developing and implementing an accreditation plan in healthcare environment
• Master's or similar degrees in healthcare administration, such as MBA, MHA, MS, MPH, or MPA
• Additional certification in healthcare quality management from a recognized organization
• Expert knowledge of regulatory environment including Joint Commission, CMS, National Committee for Quality Assurance (NCQA)

Knowledge, Skills, Abilities and Other Characteristics

• Excellent verbal and written communication skills necessary to communicate with all levels of staff and a patient population composed of diverse cultures and age groups
• Excellent program development, management and leadership skills
• Strong customer service and empathy skills
• Must be able to work flexible hours
• Must be able to travel throughout Cook County
• Performs other duties as assigned

Physical and Environmental Demands

This position is functioning within a healthcare environment.The incumbent is responsible for adherence to all hospital and department specific safety requirements.

This includes but is not limited to the following policies and procedures : complying with Personal Protective Equipment requirements, hand washing and sanitizing practices, complying with department specific engineering and work practice controls and any other work area safety precautions as specified by hospital wide policy and departmental procedures.

The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification.

They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of the personnel so classified.

FILING.

Degrees awarded outside of the United States with the exception of those awarded in one of the United States’ territories and Canada muse be credentialed by an approved U.

S. credential evaluation service belongings to the National Association of Credential Evaluation Services (NACES) or the Association of International Credential Evaluators (AICE).

Original credentialing documents must be presented at time of interview .

• Please note all offers of Employment are contingent upon the following conditions : satisfactory professional & employment references, healthcare and criminal background checks, appropriate licensure / certifications and the successful completion of a physical and pre-employment drug screen.
• CCH is strictly prohibited from conditioning, basing or knowingly prejudicing or affecting any term or aspect of County employment or hiring upon or because of any political reason or factor.

COOK COUNTY HEALTH IS AN EQUAL OPPORTUNITY EMPLOYER.