System Director Accreditation
Requisition #: 61132
Total hours worked per week: 40+
SPECIFIC DUTIES
Total hours worked per week: 40+
Description
Find your perfect match with Munson Healthcare
We’re northern Michigan’s largest healthcare system and we are deeply rooted in the communities we serve. That means that our patients are often our family, friends and neighbors – and it’s special to be able to care for them. And as one of the top healthcare systems to work for in Michigan by Forbes (American’s Best Employers by State 2022), we’re committed to your ongoing growth and development.
What we’re looking for:
- Someone with a passion for connecting with people and explaining the why
- Promote Excellence by overseeing all accreditation and compliance efforts for Munson Healthcare
The ideal candidate will have:
- A BA or BS degree in healthcare-related field. Master’s degree in related field preferred.
- A minimum of five years’ experience with the TJC/CMS accreditation process, including comprehensive knowledge and experience in the analysis of standards compliance and the application process required.
- 5 years project management and influencing C-suite levels throughout healthcare facilities is required
- Demonstrated experience proactively leading TJC, CMS and other governing body surveys, audits, and remediation plans for citations.
- Strong organizational skills to address the gaps, lead teams to take action throughout our hospital system
What you’ll get from us:
- Full benefits, paid holidays and paid time off (up to 29 days your first year)
- Tuition reimbursement and ongoing educational opportunities
- Retirement savings plan with employer match and personal consulting
- Opportunities to grow and develop your career
- Wellness offerings, an employee assistance program and employee discounts
- Relocation assistance and more!
Sound like a good match? We want to meet you!
ENTRY REQUIREMENTS
A minimum of five years’ experience with the TJC accreditation process, including comprehensive knowledge and experience in the analysis of standards compliance and the application process required.
5 years project management and influencing C-suite levels throughout healthcare facilities is required
Demonstrated experience proactively leading TJC, CMS and other governing body surveys, audits, and remediation plans for citations. Expert ability leading and executing proactive strategies in non-survey years to assure continued readiness.
Excellent interpersonal skills required. Demonstrated ability to communicate effectively with physicians, nurses, other health care professionals, Munson Healthcare staff at all levels, as well as the executive level and external customers. Ability to maintain a calm, professional demeanor under pressure.
PREFERED SKILLS & BEHAVIORS
Possesses comprehensive knowledge of the clinical capabilities of all facilities within Munson Healthcare as well as thorough knowledge of entities’ organizational and departmental functions.
Exceptional problem-solving skills. Excellent customer service orientation skills necessary in order to deal effectively with various levels of hospital personnel, outside customers, and community groups.
Requires independent judgment and action skills. Must maintain high level of confidentiality and ability to prioritize multiple tasks/activities. Strong organizational skills and the ability to concentrate while being subject to multiple interruptions and changing work priorities.
Self-directed; able to work effectively and efficiently with multiple interruptions and changing work priorities. Strong organizational and time management skills required. Able to make quality, independent decisions using analytical and problem solving skills. Demonstrates initiative and creativity in assigned work. Highly detailed and team oriented.
Demonstrated ability to lead/direct others and to work effectively with persons of varied backgrounds, education, and experience.
Demonstrates knowledge of confidentiality as it pertains to HIPAA and the handling of information sensitive to Munson Healthcare.
ORGANIZATION
Reports to the System VP of Quality & Safety. Works in close collaboration with C-Suite leaders across the organization, including at each entity, the Chief Medical Officer; Chief Nursing Officer; Medical Staff Services; quality, safety and risk leaders; Infection Prevention Manager; Director of Safety and Security; the Director of Corporate Compliance, and others.
SPECIFIC DUTIES
Supports the Mission, Vision and Values of Munson Healthcare
Embraces and supports the Performance Improvement philosophy of Munson Healthcare.
Promotes personal and patient safety.
Actively leads, develops, researches, and executes programs that strengthen a safety culture and create a safe environment for quality patient care.
Responsible for healthcare system activities and metrics in support of maintaining regulatory compliance.
Serves as a role model for patient quality and safety throughout the organization. Maintains a working knowledge of applicable Federal, State, and local laws and regulations, the Corporate Compliance Program, Code of Ethics, SMDA, EMTALA, and patient safety, as well as other policies and procedures, and understands the role of other organizational leaders for each in order to ensure compliance.
Performs mock surveys to identify areas of focus within each entity and across the system
Present and actively involved during any survey at any entity
Takes learnings from surveys at any entity and shares those learnings across the system
Directs and oversees the process of application to the accrediting body (The Joint Commission).
Leads system coordination of completion of the Periodic Performance Review with appropriate departments/services.
Submits reports developed by departments/services based on “recommendations for improvement” to The Joint Commission.
Communicates new regulatory requirements to appropriate administrators, physicians, and other health care professionals. Serves as chief internal consultant for the interpretation of regulatory standards and the elements of performance of those standards.
Works in collaboration with other appropriate staff and departments to deliver education for compliance with regulatory standards.
Point person for unannounced surveys and facilitates required efforts in support of them; coordinates work flow of multidisciplinary response team; assures communication with executive team. Demonstrates initiative and judgment in adapting or devising solutions to meet unexpected or unusual conditions inherent in unannounced surveys.
Develops and delivers required post-survey response to The Joint Commission, the Michigan Department of Community Health, and CMS. Maintains record and delivers leadership awareness of progress to address deficiencies.
Advises executive team and organization leaders regarding areas of concern and priorities related to regulatory compliance.
Leads and develops Accreditation Compliance team and manages department operations.
Develops and implements unit goals and objectives annually throughout Munson Healthcare facilities
Delegates to staff the authority necessary for the performance of their duties and ensures that adequate controls exist to render delegation effective
Develops and recommends annual Capital Equipment and Operations Budgets. Is accountable for maintaining the integrity of the unit budget; utilizes resources appropriately.
Performs other duties and responsibilities as assigned