Director, Accreditation, Regulatory and Clinical

The Director of Accreditation is responsible for establishing and maintaining a continuous survey readiness culture for Prince Georges 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 customers name as soon as it is learned.

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

4. Keeps customers 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 customers 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 department.

Communication Etiquette:

1. Respectful courteous and professional in all forms of communication and follows facilitys service communication protocol in all interactions.

2. Refrains from use of personal cell phone in patient care areas and keeps usage to a minimum at all other times while on duty.

3. Does not text or use e-mail during meetings (except for exigent or emergency situations).

4. Limits use of business cell phone during meetings (remain on vibrate and/or calls go to voicemail).

5. Makes every effort to answer telephone calls within three rings introducing him/herself department and title (if appropriate). Asks permission before placing the caller on hold or using the speakerphone. If caller is transferred gives the caller the extension number of the person he or she is being transferred to. Offers further assistance to the caller upon completing the conversation.

6. Maintains an appropriate voicemail message and when away from the office has an out-of-office email message that is brief current and includes name and department and offers the caller options if possible.

7. Returns email and voicemail messages promptly but no later than within one business day (24 hours).

8. Always mindful of voice and language in public.

Self Management:

1. Reports to work appropriately groomed and in compliance with the Hospitals dress code. Wears identification badge at all times at chest level and facing outwards so identification is clearly visible.

2. Complete all assignments within deadlines or negotiates alternative actions and time frames in order to achieve desired outcomes.

3. Completes mandatory annual education and competency requirements.

4. Follows UMCAP safety infection control and employee health standards.

5. Demonstrates responsibility for personal growth development and professional knowledge and competency.

6. Adhere to all UMCAP and department policies and procedures including Code of Conduct and professional behavior standards. Does not exceed Hospital guidelines in reference to attendance punctuality and use of sick and unplanned absences. Provides notification of absences lateness and vacation requests according to department guidelines. Respects length of time for lunch and break times.

7. Reviews signs and adheres to UMCAP and/or departmental confidentiality statement.

Qualifications :

Required: National Certification (CPHQ or related) in good standing is required (If not currently obtain w/in two years of employment date).

Preferred: Current Maryland License in related field (i.e. nursing physical therapy etc.) and/or National Certification in good standing is required.

Attained Level: Graduation from an accredited school with a Masters degree in the health sciences field is required or equivalent work experience in the field with advanced education.

Preferred: MSN

Required: 5 years of progressive responsibilities with lead/supervisory experience.

Problem Solving/Analytical Skills & Abilities: High level problem solving ability to ensure compliance with all federal TJC state and local regulatory requirements. Level of Supervision Required Ability to work autonomously with the support from manager.

Additional Information :

All your information will be kept confidential according to EEO guidelines.

Compensation:

Pay Range: $77.54-$123.81
Other Compensation (if applicable): Shift differentials
Review the 2024-2025 UMMS Benefits Guide