Accreditation Program Manager

Hennepin Healthcare is an integrated system of care that includes HCMC, a nationally recognized Level I Adult Trauma Center and Level I Pediatric Trauma Center and acute care hospital, as well as a clinic system with primary care clinics located in Minneapolis and across Hennepin County. The comprehensive healthcare system includes a 473-bed academic medical center, a large outpatient Clinic & Specialty Center, and a network of clinics in the North Loop, Whittier, and East Lake Street neighborhoods of Minneapolis, and in the suburban communities of Brooklyn Park, Golden Valley, Richfield, and St.

Anthony Village. Hennepin Healthcare has a large psychiatric program, home care, and operates a research institute, philanthropic foundation, and Hennepin EMS. The system is operated by Hennepin Healthcare System, Inc., a subsidiary corporation of Hennepin County.

We believe equity is essential for optimal health outcomes and are committed to achieve optimal health for all by actively eliminating barriers due to racism, poverty, gender identity, and other determinants of health. We are committed to equitable care and working in an environment that celebrates, promotes, and protects diversity, equity, inclusion, and belonging. We are committed to bringing in individuals with new cultural perspectives to assist in creating a more equitable healthcare organization.

We are currently seeking an Accreditation Program Manager to join our Performance Measurement and Improvement team. This full-time role will primarily work on-site (days).

This position serves as the primary contact and advisor regarding matters related to The Joint Commission (TJC) accreditation and Centers for Medicare and Medicaid Services (CMS) regulations including interpretation and education of new standards, assessment of compliance, identification of opportunities for improvement, and facilitating efforts to achieve and maintain compliance. Responsible to design and direct effective implementation of the compliance plan for the hospital and clinics to ensure survey readiness, in addition to overseeing the organizational policy process.

• Provides leadership and coordination to achieve compliance with TJC standards and CMS regulations
  • Advises the senior administrative and physician leaders of emerging needs, critical issues, achievements and changing requirements
  • Provides recommendations to senior administrative and physician leaders regarding action strategies to achieve or maintain compliance with standards/regulations
  • Provides on-going review, evaluation, interpretation of standards/regulations, and requirements when there are changes, revisions, and new standards/regulations
  • Coordinates and monitors compliance related to the implementation of TJC standards and CMS regulations
  • Serves as the organization's primary resource and advisor related to TJC accreditation and CMS regulations for other internal and external regulatory agencies
  • Develops, coordinates, and disseminates information to the Regulatory Steering Committee
• Develops systems and structures to support continual readiness
  • Designs and implements evaluation processes and tools to assess the level of compliance with TJC standards and CMS regulations
  • Designs and implements reporting processes to assure that leaders have the information they need to improve performance for areas of non-compliance
  • Directs activities designed to improve performance in areas of significant need across the organization
  • Develops and implements strategies to various organizational committees to communicate assessment findings and report progress, barriers, and successes
  • Develops process to manage implementation of required requirements such as policies, procedures, standard work, and/ or reports
  • Assesses systems for data collection and analysis of regulatory standards information and provides recommendations for improvement
  • Assists in developing data collection systems to ensure performance measures are tracked and trended for identified improvement strategies
• Manages assigned staff, facilitates standard work and coaching/developing of staff
  • Provides oversight and direction for the Accreditation Program Specialist(s) to implement standard work
  • Provides direction for ongoing activities for regulatory survey readiness
  • Guides workflows to ensure effective outcomes for regulatory compliance
  • Support activities for team members to participate in educational development for regulatory compliance
• Coordinates TJC survey and CMS/Minnesota Department of Health (MDH) survey activities
  • Serves as key contact with TJC for all survey preparations and on-site activities
  • Serves as the key contact for all CMS/MDH survey onsite-activities
  • Coordinates all on-site survey preparations including identifying survey participants, scheduling, logistics, and survey accommodations
  • Coordinates all required follow-up and formal responses related to findings
• Provides and coordinates implementation…