Corporate Quality, Regulatory & Accreditation Manager

Company Overview

Shriners Children’s is a family that respects, supports, and values each other. We are engaged in providing excellence in patient care, embracing multi-disciplinary education, and research with global impact. We foster a learning environment that values evidenced based practice, experience, innovation, and critical thinking. Our compassion, integrity, accountability, and resilience defines us as leaders in pediatric specialty care for our children and their families.

Job Overview

Shriners Children's is the premier pediatric burn, orthopaedic, spinal cord injury, cleft lip and palate, and pediatric subspecialties medical center. We have an opportunity for a Corporate Quality, Regulatory & Accreditation Manager reporting into our Corporate Headquarters.

The Corporate Quality, Regulatory & Accreditation Manager will support the organization in facilitating and executing quality, safety and regulatory initiatives. The candidate will be accountable for goal setting, project targets and timelines to meet regulatory requirements, patient safety initiative timelines, or other identified opportunities for process or technical improvements. This position collaborates with key Shriners Children's (SC) stakeholders to improve organizational safety, efficiency, systems and/or processes. The position supports and facilitates system wide Medical Affairs/Healthcare Quality initiatives and SC corporate goals/objectives. This position is the subject matter expert for regulatory readiness and provides consultation to SC leadership and staff. Additionally the candidate provides interpretation, guidance and facilitation for Medical Staff Bylaws, Hospital Regulations and Procedural Rule changes. The position requires understanding and use of measures and measurement program[s], evidence-based clinical practices, protocols, process redesign teams and other methodologies.

Occasional travel to sites will be necessary for this role.

Responsibilities

• Creates and participates in high performing teams/taskforces that effectively collaborate with hospital and corporate leaders and staff to drive conformity to regulations and address identified opportunities for improvement. Leads each project in the development of its charter, setting goals, project implementation and adherence to projected timelines and milestones.
• Monitors activities of external agencies (such as CMS, TJC, AORN, AAMI, SHEA, APIC, OSHA, etc.) and provides consultation, education, interpretation of standards and communication to stakeholders for accreditation, regulations, infection prevention/occupational health, clinical quality, patient safety, risk management and facilitates policy and form development and maintenance.
• Provides regular leadership for SC system affinity groups for Infection Preventionists/Occupational Health, Infection Prevention Advisory Council, and participates in corporate committees, workgroups and taskforces as indicated.
• Conducts CMS deemed status mock surveys to support hospital and ASC compliance with accreditation, licensing and regulatory agencies. Provides follow-up and ongoing support for continued survey readiness.
• Supports local hospital/facility leaders with unannounced regulatory surveys and guides corporate and hospital leaders with responses to regulatory agencies to show corrective actions or evidence of compliance to standards/requirements.
• Actively participates in amendment process for hospital regulations, procedural rules, medical staff bylaws, corporate policy development/review process, as well as, corporate and hospital forms review and approval process.
• Orients, educates, communicates, leads and supports hospital Performance Improvement Directors, Quality Managers, Risk Management, Infection Preventionists and Occupational Health staff in the design, management and execution of site specific QA/PI, Patient Safety and Infection Control Plans, regulatory requirements, corporate policy and performance improvement projects related to their work.

Qualifications

Experience:

• 5 Years of healthcare experience required
• Knowledge and experience in performance improvement methodologies required
• Lean Six Sigma experienced preferred
• 5 years of project management experience preferred
• Demonstrated leadership of multi-disciplinary, multi-location, and/or virtual staff preferred
• Experience with extracting data/reports and conducting analysis-Preferred
• Working knowledge of The Joint Commission, Federal and State regulatory standards for acute, ambulatory care, rehabilitation, is required.
• Experience in providing reports and data analysis to various stakeholders.

Education/Licensure:

• Bachelor's Degree in Nursing (BSN) required
• Maintenance of a current RN license in State of residence required
• Master's Degree in a health-related field preferred
• CPHQ or CTJC preferred