Manager of Accreditation and Regulatory Readiness

Overview

The Manager of Accreditation and Regulatory Readiness reports to the Brown University Health Director, Accreditation and Regulatory Readiness. Under general supervision and within Brown University Health established policies and procedures, performs a wide variety of duties in managing accreditation and regulatory compliance across Brown University Health, including standards and expectations from the Joint Commission (TJC), CMS, the Department of Health, centers of excellence, certification and other related accreditation and regulatory requirements.

Ensures that all Brown University Health affiliates maintain continuous compliance with state and federal regulatory and accrediting agencies’ standards. Manages complex projects potentially crossing multiple systems, platforms, and all Brown University Health affiliates. Provides consultation to leadership, key stakeholder groups and ad hoc teams on accreditation and other regulatory-related performance improvement activities. Implements improvement strategies and tactics by working collaboratively with other disciplines within Brown University Health.

• Consistently applies and serves as a role model for the Brown University Health shared “CARE” values of Compassion, Accountability, Respect and Excellence
  .
• Is responsible for knowing and acting in accordance with the principles of the Brown University Health Corporate Compliance Program and Code of Conduct.
• Provides support and leadership for Brown University Health’s Quality Priorities service and treatment settings.
• Develops and manages an approach to a proactive, systematic, objective, and continuous process of self-assessment of Brown University Health compliance and readiness with all TJC, CMS, DOH and related regulatory and accreditation standards in partnership with key stakeholders across the system.
• Develops a process that includes ongoing mock survey audits and tracers for compliance with TJC and CMS standards. Leads and coordinates the interpretation of results and development of action plans across all affiliates to address areas needing improvement.
• Guides Brown University Health affiliates to meet external and regulatory standards of TJC, CMS and the RI Department of Health. Develops and implements strategies to ensure continuous readiness for external unannounced surveys or reviews. Advises senior management and executive leadership at each affiliate and at the system level of potential vulnerabilities and recommends improvement or corrective actions to maintain compliance.
• Develops and implements a robust communication system that effectively informs all involved stakeholders about accreditation requirements, implications, and changes. Disseminates information clarifying regulatory and accreditation standards and organizes departmental and interdepartmental survey preparation and responses.
• Develops and manages a proactive, systematic, and continuous process for improving readiness and compliance with all standards and requirements for Brown University Health using a project management approach.
• Leads efforts for ongoing accreditation assessment and survey preparation-related activities.
• Assists leadership in identifying, developing, and maintaining needed accreditation-required policies and procedures.
• Collaborates with key stakeholders to ensure accreditation-related training and education requirements for Brown University Health staff are met or exceeded. Maintains current working knowledge of all relevant regulatory and accreditation standards.
• Performs other duties as assigned.

• Effective utilization of resources
• High quality, high value patient-focused services
• Resource productivity
• Fiscal responsibility
• Development and implementation of effective quality programs
• Customer satisfaction
• Performance improvements year-to-year
• Positive feedback from peers, directs reports and staff

• A bachelor’s degree in health administration, nursing or healthcare professional field is required. Advanced degree in related field preferred.
• Must possess a relevant professional certification (e.g., CPHQ or equivalent).
• Experience with…