Job Abstract

Job Description:

The Director of Accreditation is responsible for directing, implementing, and maintaining Joint Commission, and other accreditations and certifications to ensure continual organizational compliance with all applicable standards and readiness for announced and unannounced surveys.

Scope: Hospitals and clinics including off-site clinics.

Essential Job Functions:

• Provides strategic and tactical planning and development for a proactive program of continuous readiness for accreditation/regulation.
• Oversees institutional policies, readiness calendar and support resources, including educational curriculum related to accreditation and regulatory requirements of the Joint Commission, Clinical services accreditation and regulation for the organization (e.g. The Joint Commission (TJC) and Center for Medicare and Medicaid Services (CMS)) and for specialty services (e.g. ACS Trauma certification, Comprehensive Stroke Disease-Specific certification) and numerous other accreditation and regulatory bodies.
• Manages the continual organizational assessment and preparation for accreditation/regulation processes for the organization.
• Responsible for all Medicare, Medicaid, and Managed Care reimbursements which are dependent on accreditation, therefore the entire budget for the clinical enterprise and funds that flow to Support Services, Schools, and Research from the clinical enterprise.
• Provide direction, advice, and support to chapter experts to ensure that they are up to date on standard changes and anticipate organizational implications.
• Evaluate all new clinics and services for accreditation/regulation compliance; develop, implement, and evaluate actions needed in these new areas to bring them into compliance.
• Assesses training needs in consultation with the Joint Commission chapter experts and hospital and clinic departments to develop the human resources to accomplish the strategic goals of accreditation for the clinical enterprise.
• Coordinates educational efforts related to accreditation/regulation across the clinical enterprise.
• Collaborate with intercampus subject matter experts to design, develop & deliver training and in-service programs.
• Works with leadership, department directors, and physician groups to meet information and education needs related to accreditation/regulatory standards.
• Oversees the development of education to leadership, physicians, and staff throughout the organization on accreditation issues.
  • Assist with needs assessment for areas
  • Develop, design, implement, and evaluate educational programs based on needs assessment and inspection (e.g. mock surveys)
• Coordinates all responses to external accrediting or regulatory agency visits (scheduled and unannounced) by managing the process, and staff involved and documenting and facilitating issue resolution and corrective action plans.
• Maintains familiarity with all applicable accreditation standards, and with changes in those standards; communicates these changes, according to need, to leadership, chapter experts, and staff throughout the organization.
• Coordinates and tracks continuous readiness tracers, mock surveys, and any other preparatory and corrective activities throughout the organization including off-site clinics.
• Establishes mechanisms to assess and document the organization’s level of compliance with applicable standards.
• Coordinates and oversees the establishment of mechanisms to correct areas of non-compliance with applicable standards.
• Proactively communicates areas of strength as well as needs/vulnerabilities to hospital leadership and oversight groups/committees.
• Provides consultation re: accreditation standards and corrective actions to individuals, special projects, and executive and clinical departments throughout the organization.
• Participates in university initiatives as assigned by executive leadership.
• Facilitates and serves on various committees as requested.
• Provides input into operating and capital equipment budgets.
• Adheres to internal controls and reporting structure.
• Performs other duties as assigned.

Knowledge/Skills/Abilities:

• Strong communication and interpersonal skills with a high degree of professionalism and diplomacy in dealing with staff at all levels of the institution and external agencies.
• Effective problem-solving skills and the ability to influence others who have no direct reporting relationship.
• Ability to develop, prioritize, and accomplish goals.
• Knowledge of and ability to function in a participatory management environment which involves clinical department chairmen, division chiefs, hospital administrators, and various levels of management within a large academic medical center or related environment in the identification and resolution of problems, development of plans, objectives, and strategies.
• Strong presentation skills and abilities.