Summary:
The Director Accreditation Regulatory Readiness & Patient Safety reports to the Vice President of Quality and Safety. Under general supervision and within Lifespan established policies and procedures performs a wide variety of duties in leading and managing all aspects of accreditation and regulatory compliance across Lifespan and its affiliates 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 Lifespan affiliates maintain continuous compliance with state and federal regulatory and accrediting agencies standards. Develops and implements high quality and high value applications to meet customer needs and expectations. Manages complex projects potentially crossing multiple systems platforms and all Lifespan affiliations. 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 Lifespan.
Directs and manages coordination collection and analysis of patient safety data for internal comparison and external reporting through Lifespans electronic event reporting system (SafetyNet) to the Patient Safety Organization (PSO). Provides oversight for the medical event reporting workflow to ensure appropriate timely root cause identification and analyses and related improvement project timelines. Establishes and maintains processes to ensure timely event review to ensure relevant internal action as well as timely event data submission to the Patient Safety Organization via SafetyNet. Provides strategic leadership and oversight for the development implementation and evaluation patient safety metrics and their associated processes to achieve optimal outcomes compliance with evidenced-based care and identifies need for improvement when necessary.
Responsibilities:
Consistently applies and serves as a role model for the Lifespan shared CARE values of Compassion Accountability Respect and Excellence . Is responsible for knowing and acting in accordance with the principles of the Lifespan Corporate Compliance Program and Code of Conduct. Provides support and leadership for Lifespans Quality Priorities service and treatment settings.
Develops and manages approach to a proactive systematic objective and continuous process of self-assessment of Lifespan 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.
Ensures that all Lifespan affiliates 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. Promotes shared learning using existing effective communication channels wherever possible before developing additional means.
Develops and manage a proactive systematic and continuous process for improving readiness and compliance with all standards and requirements for the Lifespan using a project management approach.
Provides consultation to leadership stakeholders and ad hoc teams on accreditation and other regulatory-related performance improvements. Promote continuous clinical and service process improvement through effective leadership team facilitation consultation and project management support to Lifespan and its affiliates.
Leads efforts for ongoing accreditation assessment and survey preparation-related activities. Leads the identification collection and analysis of meaningful information for guiding improvement efforts.
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 Lifespan staff are met or exceeded. Maintain current working knowledge of all relevant regulatory and accreditation standards.
Assigns trained staff to lead RCA activities. Provides project management data gathering and analysis and decision-making support for department initiatives focused on clinical patient safety measures reporting and improvement. Identifies issues through failure analysis; leads or assists improvement teams in understanding issues and improvement opportunities. Provides tracking and oversight for all performance improvement plans and ensures implemented actions are effective by requesting and evaluating objective data in support of improved outcomes. Oversees processes identified within the Lifespan Patient Safety Evaluation System (PSES) and for the protection of Lifespan Patient Safety Work Product (PSWP).
Ensures successful implementation of the tools of Lean Six Sigma through implementation of the Care Transformation Quality and Safety program at Lifespan. Develops and implements strategies for adoption of Lean Six Sigma by medical staff leadership and staff across Lifespan to drive high quality patient care organizational productivity and positive financial results. Using the tools of Lean Six Sigma conducts assessments of organizational effectiveness at system hospital and department levels.
Collaborates with educational and professional development in the design and implementation of education and safe practice standards/policies; oversees the analysis and communication of sentinel event alerts and other similar alerts; maintains current knowledge of patient safety standards including Joint Commission's National Patient Safety Goals; collaborates with other safety leaders across the system to assure compliance with such required standards; recommends and collaboratively works with leadership and staff in the completion of proactive risk assessments.
Performs other duties as assigned.
PERFORMANCE STANDARDS:
Effective utilization of resources
Management of continuous quality improvement
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
Performance improvements year-to-year
Positive feedback from peers directs reports and staff
Other information:
QUALIFICATIONS-EDUCATION:
Baccalaureate degree in health services administration nursing business administration public health or related field required. A masters degree in health administration or healthcare professional field is required. Formal education in clinical informatics strongly preferred. Six Sigma Green Belt and/or Black Belt Certification required within 18 months of assuming role.
QUALIFICATIONS-EXPERIENCE:
At least seven years experience managing and supporting organizational accreditation (Joint Commission and CMS) required. Prior experience in a healthcare setting with experience in Healthcare Outcomes Surveying Statistical Analysis Benchmarking and Research Methodology is required. Experience with the principles and practices of health care quality management preferred. Project management experience preferred. Working knowledge of all Microsoft Office software applications required. Minimum of seven (7) years of related work experience is also required.
Position requires deep knowledge and understanding of patient safety science specific tactics and strategies for enhancing the culture of safety as well as subject matter expertise in the evaluation of medical errors and corrective action planning.
Position requires excellent communication skills including the ability to communicate information effectively to others both verbally and in writing. Position duties require the ability to make various presentations internally and externally.
SUPERVISION:
Supervisory responsibilities for up to 20 professional and support staff. Includes selection direction and evaluation of work. Includes indirect supervision of other staff medical staff volunteers visitors vendors with respect to regulatory readiness issues.
Lifespan is an Equal Opportunity / Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race color religion sex national origin age ethnicity sexual orientation ancestry genetics gender identity or expression disability protected veteran or marital status. Lifespan is a VEVRAA Federal Contractor.
Location: Corporate Headquarters USA:RI:Providence
Work Type: Full Time
Shift: Shift 1
Union: Non-Union
