SHS-REGIONAL DIRECTOR ACCREDITATION & CLINICAL IMPROVEMENT

General Purpose of Job:

This position is responsible for the Accreditation Plan for the University of Michigan Health - West and Sparrow Health System that promotes continuous and sustained compliance to CMS (Centers for Medicare/Medicaid Services), Joint Commission Conditions of Participation, and the Accreditation Commission for Health Care. Accreditation Readiness focuses on standardized core processes and develops cross functional work teams who understand the rationale of the standards for compliance. Accreditation Leadership gives organizational excellence, improved workflow, and risk mitigation.

This individual is responsible for programming activities across the regional health system to identify, prevent, and reduce the risk of harm to our patients, visitors, and caregivers. Prioritized strategies include, but are not limited to:

• Establishing accountability of reporting structure all community hospitals to system quality governing board.
• Establishing separate hospital and health system Accreditation Readiness Steering Committees.
• Communicating Joint Commission and Vizient data trends to providers and stakeholders.
• Building decision making based off data from SAFER Matrix and/or CMS surveys.
• Identifying opportunities for Performance Improvement and overseeing action plan processes.

The ultimate purpose of this role is to effect the cultural change necessary to execute and sustain the Regional Operations Vision to be a national leader in quality and patient safety. Provides leadership and subject matter expertise for Accreditation for the University of Michigan. Facilitates compliance with all regulatory bodies including CMS Conditions of Participation. Develops program for continued preparedness for accreditation and works in conjunction with executive leaders to promote readiness

Essential Duties

• Participates in the development of and implementation of strategic initiatives in support of quality of care related to regulatory and accreditation compliance by the following initiatives through the Accreditation Plan that will set the direction and foundation to develop strategies to execute change for success for the near and future.
• Perform Mock Surveys/Tracers for continual identification of compliance.
• Perform annual Joint Commission Mock Surveys for identification of risk opportunities.
• Perform Joint Commission Chapter owner meetings with key stakeholders.
• Develop chapter evidence compliance manuals.
• Respond to scheduled and unscheduled survey/investigation events.
• Comply with all federal, state, and local regulations pertaining to regulatory compliance.
• Communicate and collaborate with department leadership and caregivers to effectively achieve plan goals.
• Consult with experts to broaden knowledge on risk mitigation and assessments.
• Evaluate the effectiveness of the Accreditation Plan annually by reviewing tracer data and the intracycle monitoring assessment to determine if strategies and interventions were effective. Prioritized goals are developed from this annual review process.
• Develop leadership knowledge of regulatory requirements and guidelines to ensure continual compliance.
• Demonstrate compliance with relevant regulatory and accreditation requirements: The Joint Commission, CMS, ACHC, and OSHA.

• The Regional Senior Leadership gives authority to the Regional Associate Chief Quality Officer and/or Regional Accreditation Director to direct and institute activities specifically related to CMS, Joint Commission, and ACHS Standard compliance.
• Drives process implementation to ensure overall compliance - Each hospital has an Accreditation Life Cycle that outlines expectations from the last survey to the next for both accreditation and certification surveys. Within these Accreditation Life Cycles, activities include Joint Commission tracer rounding via AMP Tool, chapter owner meetings, mock surveys, and risk gap identification meetings.
• Harvest, distill, and disseminate best practices from all University of Michigan care organizations to support achievement of performance targets.
• Direct efforts to identify opportunities for optimization, standardization and continuous quality improvement based on evidence-based practices, regulatory and accrediting agency requirements.
• Work collaboratively with Regional University of Michigan leaders to respond to a rapidly changing environment and complete special projects as assigned.
• Conduct an annual assessment of the regional alignment of compliance with consistent execution of evidence- based tactics and behaviors that are critical to achieve results.