Director, Regulatory & Accreditation

Job Summary

The Director, Regulatory & Quality is responsible for conducting organizational preparedness to ensure Westchester Medical Center demonstrates ongoing compliance and survey readiness with respect to state and federal regulations and other agency accreditation/certification requirements. This is a position with responsibility for an organization-wide program to promote the delivery of high quality and fiscally responsible health care.

Responsibilities

• Directs and supervises the integration and coordination of all components to facilitate the efficient delivery of value added care and services
• Is the primary liaison to regulatory agencies and accreditation bodies for WMC and is the central point of contact for division(s) within the medical center related to matters of regulatory functions, standards and compliance, accreditation and licensure standards
• Implements and devises a systematic approach to achievement of compliance with all licensing & accreditation standards & requirements, ensuring consistency with organizational goals & priorities
• Directs a regulatory survey readiness at each of the organization's locations
• Pairs with the Quality Directors to prepare for surveys & inspections, including educational forums, coordinating mock surveys & assessments, assists in developing response plans
• Facilitates coordination of surveys for all regulatory & accrediting agencies
• Provides leadership in establishing a high level of awareness of regulatory and accrediting agency requirements throughout the Medical Center including ramifications of failures in compliance
• Interprets and communicates existing and new requirements, standards, and regulations and advises and coordinates with leadership, the medical staff including recommendations and guidance for application of external regulations and standards
• Initiates, plans for, communicates, monitors and evaluates actions to comply with existing and new regulations, standards and accreditation requirements
• Collaborates, develops, evaluates and provides direction for continuous improvement in hospital-wide performance improvement to ensure effectiveness through data analysis and education of employees in conjunction with other department directors
• Assesses the Medical Center's compliance with federal and state regulations continued survey readiness, and participates with the Vice President, Regulatory & Accreditation, the Vice President of Quality and other directors in Quality to coach hospital leadership in survey preparation
• Leads the development and implementation of corrective action plans for consistency and improvement of identified non-compliance issues and ensures timely preparation and submission of responses to survey findings
• Establishes mechanisms tracking of corrective actions
• Develops, implements, monitors and communicates findings of an audit program to monitor compliance with standards and regulations
• Ensures efficiency, effectiveness and accuracy of data collection, analysis and reporting to drive performance improvement processes, and presents data in easy to understand dashboards that clearly display trends so as to assist department and leadership decision making
• Partners with the Risk Management department to link regulatory compliance with risk management activities to reduce medical/legal liability
• Advise the development and implementation of educational programs/materials to be utilized in meeting requirements of State and Federal regulations and accreditation standards
• Promotes and provides quality customer service, and proactively identifies and resolves customer issues that relate to quality and performance improvement activities
• Reviews protocols, policies and procedures to facilitate compliance with CMS and all other applicable accrediting organizations and regulatory bodies
• Facilitates the implementation of necessary changes in practice, policy and procedures to maintain compliance with changes in regulatory requirements
• Prepares department's operating and capital budget in conjunction with the Vice President, and assists with monitoring department's budgets and expense
• Performs related duties as assigned

Qualifications/Requirements

• Experience: 2 years managerial experience which includes activities associated with regulatory survey processes, development, implementation and follow-up of regulatory plans of correction in or for a hospital or health care agency
• Education: Bachelor's degree, required. Satisfactory completion of 30 credits toward a Master's degree may be substituted on a year for year basis for up to two years of the above stated experience, exclusive of the specialized experience
• Licenses / Certifications: CPHQ or Project Management certification preferred