Director, Regulatory and Accreditation #1 - St. John’s Episcopal Hospital : Job Details

Who We Are St Johns Episcopal Hospital is the only hospital providing emergency and ambulatory care to the densely populated culturally and economically diverse and medically underserved populations of the Rockaways and Five Towns in southern Queens County and southwestern Nassau County New York Celebrating over 110 years of community care the 257 bed facility provides people of all faiths with comprehensive preventive diagnostic treatment and rehabilitative services regardless of ability to pay Come Grow With Us Type Full Time 75 hours biweekly Shift Days Hours 900Am 530PM Pay 145### ####00 Job Summary The primary purpose of the Regulatory and Accreditation Program at EHS is to promote safe high quality and effective patient care through maintaining accreditation certification and licensure compliance for EHS Develops and leads a comprehensive regulatory survey readiness program in support of EHSs mission values and values The Regulatory Director plans implements and directs activities that supports EHS compliance with city state and federal regulatory requirements and associated accreditation requirements Reporting directly to the Chief Quality Officer Responsibilities Establishes guidelines to meet The Joint Commission accreditation requirementsPlans implements and directs programs to support continuous survey readiness activities in collaboration with subject matter experts across the organizationImplements educational programs and current resources to support regulatory compliance and survey readiness as part of day to day operationsDirects organizational survey readiness and continuous compliance activities including ongoing monitoring through observations of clinical and clinical support areasPartners with EHS Leadership to implement risk reduction and continuous compliance activitiesLeads on site planned and for cause surveys and inspections in coordination with EHS Leaders and subject matter expertsLeads post survey activities including but not limited to collaboration with leaders on the development of action plans authoring corrective action plans and other standards compliance plans and coordination of follow up surveyinspection plansLeads facilitates and supports organization and System level programs and projects integral to standardizing safe clinical practices and achieving and maintaining regulatory complianceServes as the organizations point of contact for accreditation and all regulatory agencies NYSDOH CMS Joint Commission as well as other external partnersThe Regulatory Director is also responsible for EHS Policy Management programs to ensure compliance with regulations and legal statute Ensures evidence based practice is fundamental in resource document processesDevelops and maintains a comprehensive project plan linked to standards with on going monitoring and reporting to senior managementServes as the EHS subject matter expert related to accreditation and regulatory standardsCollaborates with EHS senior management and clinical staff in leading and managing all aspects of the accreditation process and standard adherenceConducts training and coaching to support understanding of accreditation standards and requirementsDevelops and manages audit activities to ensure compliance with accreditation standards and develops and maintains a dashboard to demonstrate ongoing complianceRequirements Bachelors degree required Masters Degree preferredExpert knowledge of regulatory environment including NYCDOHMH NYSDOH Joint Commission CMS National Committee for Quality Assurance NCQA3 7 years of experience with accreditation and regulatory survey process development and follow up of corrective plansKnowledge of TJCs E edition software and JCR AMP Tracer softwareExcellent verbal and written communication skills necessary to communicate with all levels of staff and a patient population composed of diverse cultures and age groupsDemonstrate strong leadership and interpersonal communication skillsDemonstrate excellent organizational and analytical skillsProficiency using Microsoft Office and Google ProductsWork independently with minimum supervisionAbility to work under stress and in emergency situations