Associate Director of Quality Management & Accreditation - Quality Management

Minimum Qualifications:

Bachelor’s degree in nursing or a health-related field and five years of progressive responsibility, experience in a hospital and/or clinic setting, including progressive participation and management experience, with regulatory and accreditation preparation.

Required:

Must possess and maintain a current RN license or valid temporary permit to practice in Texas or a clinical degree in a health-related field. 

Preferred:

Specialty certification (CPHQ), or safety or accreditation

Preferred Qualifications:

• Master's degree in a clinical field, health management, or health-related field
• Specialty certification in quality, safety, or accreditation
• Project management and Lean experience are a plus.
• Experience in clinical care settings across the continuum is preferred, allowing in-depth analysis of the care processes surrounding patients and families.

Job Summary:

The Associate Director of Quality Management and Accreditation is responsible for directing, implementing, and maintaining health system and hospital clinical activities, Joint Commission and other regulatory agencies, accreditations, and certifications to ensure continual organizational compliance with all applicable standards and readiness for announced and unannounced surveys. Facilitates the integration of the strategic vision into clinical practice through collaboration with local leaders and the support of the Director of Quality Management & Patient Safety. The Associate Director is knowledgeable about the components of Quality Management and Regulatory compliance.

Scope: Hospitals and clinics, including off-site clinics. 

Essential Job Duties:

• Assists the Director of Quality Management and Patient Safety, in the execution and advancement of annual Performance Improvement Plans.
• Provides strategic and tactical planning and development for a proactive program of continuous readiness for accreditation/regulation.
• Oversees institutional policies, readiness calendar, and support resources, including educational curriculum related to accreditation and regulatory requirements of the Joint Commission, Clinical services accreditation and regulation for the organization (e.g., The Joint Commission (TJC) and Center for Medicare and Medicaid Services (CMS)) and specialty services (e.g., ACS Trauma certification, Comprehensive Stroke Disease-Specific certification) and numerous other accreditation and regulatory bodies.
• Manages the continual organizational assessment and preparation for accreditation/regulation processes for the organization.
• Responsible for all Medicare, Medicaid, and Managed Care reimbursements, which are dependent on accreditation; therefore, the entire budget for the clinical enterprise and funds that flow to Support Services, Schools, and Research from the clinical enterprise.
• Provides direction, advice, and support to chapter experts to ensure they are current on standard changes and anticipate organizational implications.
• Evaluate all new clinics and services for accreditation/regulation compliance; develop, implement, and evaluate actions needed in these new areas to bring them into compliance.
• Assesses training needs in consultation with the Joint Commission chapter experts and hospital and clinic departments to develop the human resources to accomplish the strategic goals of accreditation for the clinical enterprise.
• Coordinates educational efforts related to accreditation/regulation across the clinical enterprise. 
• Collaborate with intercampus subject matter experts to design, develop & deliver training and in-service programs.
• Works with leadership, department directors, and physician groups to meet information and education needs related to accreditation/regulatory standards.
• Oversees the development of education to leadership, physicians, and staff throughout the organization on accreditation issues.                            

                        o   Assist with needs assessment for areas.

                        o   Develop, design, implement, and evaluate educational programs based on needs assessment and inspection (e.g., mock surveys)

• Coordinates all responses to external accrediting or regulatory agency visits (scheduled and unannounced) by managing the process and staff involved, documenting and facilitating issue resolution, and creating corrective action plans.
• Maintain familiarity with all applicable accreditation standards and changes in those standards; communicate familiarity with all applicable accreditation standards and changes in those standards; communicate these changes, according to need, to leadership, chapter experts, and staff throughout the organization.
• Coordinates and tracks continuous readiness tracers, mock surveys, and other preparatory and corrective activities throughout the organization, including off-site clinics.
• Establishes mechanisms to assess and document the organization’s level of compliance with applicable standards.
• Coordinates and oversees the establishment of mechanisms to correct areas of non-compliance with applicable standards.
• Proactively communicates areas of strength a needs/vulnerabilities to hospital leadership and oversight groups/committees.
• Provides consultation regarding accreditation standards and corrective actions to individuals, special projects, and executive and clinical departments throughout the organization.
• Participates in university initiatives as assigned by executive leadership.
• Facilitates and serves on various committees as requested.
• Provides input into operating and capital equipment budgets.
• Adheres to internal controls and reporting structure.
• Facilitates and participates in developing and implementing assigned new initiatives, regulatory requirements, and action plans to improve clinical and operational performance, enhance services and outcomes, and enhance margins using a disciplined, team-based approach and rapid cycle improvement methods.

Marginal or Periodic Functions:

• Oversees and collaborates quality, process improvement, clinical risks, and accreditation within assigned area(s).
• Oversee Performance Improvement activities, facilitate PI teams, and support department leaders in conducting local improvements.
• Oversees reporting Core measures and value-based purchasing activities according to TJC and CMS timelines and guidelines.
• Oversees reporting Best Care and institutional initiatives for each campus.
• Oversees supervision of patient chart reviews using quality and regulatory indicates according to TJC, NQF, and AHRQ criteria/specifications.
• Works with staff to analyze outcomes, process measures, and benchmarks to identify improvement opportunities, and work with individual departments and staff to address outcomes below expected benchmarks.

Knowledge/Skills/Abilities

• Principles and practices of supervision and administration as applied to the management and direction of personnel within areas of accountability.
• Effective managerial and administrative abilities as applied to the complex environment of an academic health system, including community hospitals and ambulatory services.
• Strong communication and interpersonal skills with a high degree of professionalism and diplomacy in dealing with the staff at all times, including institutional and external agencies.
• Effective problem-solving skills and the ability to influence others who have no direct reporting relationship.
• Ability to develop, prioritize, and accomplish goals.
• Knowledge of and ability to function in a participatory management environment, which involves clinical department chairmen, division chiefs, hospital administrators, and various levels of management within a large academic medical center or related environment in the identification and resolution of problems, development of plans, objectives, and strategies.
• Strong presentation skills and abilities.

*Official Regulatory Statement for Healthcare jobs’ Job Descriptions: May be exposed to such occupational hazards as communicable diseases, blood-borne pathogens, ionizing & non-ionizing radiation, hazardous medications, and disoriented or combative patients or others.