Accreditation Program Manager

Hennepin Healthcare is an integrated system of care that includes HCMC, a nationally recognized Level I Adult Trauma Center and Level I Pediatric Trauma Center and acute care hospital, as well as a clinic system with primary care clinics located in Minneapolis and across Hennepin County. The comprehensive healthcare system includes a 473-bed academic medical center, a large outpatient Clinic & Specialty Center, and a network of clinics in the North Loop, Whittier, and East Lake Street neighborhoods of Minneapolis, and in the suburban communities of Brooklyn Park, Golden Valley, Richfield, and St. Anthony Village. Hennepin Healthcare has a large psychiatric program, home care, and operates a research institute, philanthropic foundation, and Hennepin EMS. The system is operated by Hennepin Healthcare System, Inc., a subsidiary corporation of Hennepin County.

Equal Employment Opportunities: We believe equity is essential for optimal health outcomes and are committed to achieve optimal health for all by actively eliminating barriers due to racism, poverty, gender identity, and other determinants of health. We are committed to equitable care and working in an environment that celebrates, promotes, and protects diversity, equity, inclusion, and belonging. We are committed to bringing in individuals with new cultural perspectives to assist in creating a more equitable healthcare organization.

SUMMARY

We are currently seeking an Accreditation Program Manager to join our Performance Measurement and Improvement team. This full-time role will primarily work on-site (days).

Purpose of this position: This position serves as the primary contact and advisor regarding matters related to The Joint Commission (TJC) accreditation and Centers for Medicare and Medicaid Services (CMS) regulations including interpretation and education of new standards, assessment of compliance, identification of opportunities for improvement, and facilitating efforts to achieve and maintain compliance. Responsible to design and direct effective implementation of the compliance plan for the hospital and clinics to ensure survey readiness, in addition to overseeing the organizational policy process.

RESPONSIBILITIES

• Provides leadership and coordination to achieve compliance with TJC standards and CMS regulations
  • Advises the senior administrative and physician leaders of emerging needs, critical issues, achievements and changing requirements
  • Provides recommendations to senior administrative and physician leaders regarding action strategies to achieve or maintain compliance with standards/regulations
  • Provides on-going review, evaluation, interpretation of standards/regulations, and requirements when there are changes, revisions, and new standards/regulations
  • Coordinates and monitors compliance related to the implementation of TJC standards and CMS regulations
  • Serves as the organization's primary resource and advisor related to TJC accreditation and CMS regulations for other internal and external regulatory agencies
  • Develops, coordinates, and disseminates information to the Regulatory Steering Committee
• Develops systems and structures to support continual readiness
  • Designs and implements evaluation processes and tools to assess the level of compliance with TJC standards and CMS regulations
  • Designs and implements reporting processes to assure that leaders have the information they need to improve performance for areas of non-compliance
  • Directs activities designed to improve performance in areas of significant need across the organization
  • Develops and implements strategies to various organizational committees to communicate assessment findings and report progress, barriers, and successes
  • Develops process to manage implementation of required requirements such as policies, procedures, standard work, and/ or reports
  • Assesses systems for data collection and analysis of regulatory standards information and provides recommendations for improvement
  • Assists in developing data collection systems to ensure performance measures are tracked and trended for identified improvement strategies
• Manages assigned staff, facilitates standard work and coaching/developing of staff
  • Provides oversight and direction for the Accreditation Program Specialist(s)to implement standard work
  • Provides direction for ongoing activities for regulatory survey readiness
  • Guides workflows to ensure effective outcomes for regulatory compliance
  • Support activities for team members to participate in educational development for regulatory compliance
• Coordinates TJC survey and CMS/Minnesota Department of Health (MDH) survey activities
  • Serves as key contact with TJC for all survey preparations and on-site activities
  • Serves as the key contact for all CMS/MDH survey onsite-activities
  • Coordinates all on-site survey preparations including identifying survey participants, scheduling, logistics, and survey accommodations
  • Coordinates all required follow-up and formal responses related to findings
• Provides and coordinates implementation of education, training, and consultation in relation to identified learning needs
  • Conducts a needs assessment for various individuals, teams and committees regarding the understanding and interpretation of TJC standards and CMS regulations
  • Develops educational methods and tools to meet the defined learning needs across the organization
  • Develops and implements communication mechanisms to support continual survey readiness activities; communicates assessment findings and celebrates successes
• Stays current with TJC standards, CMS regulations and survey methods
  • Maintains current expertise in all aspects of TJC accreditation and CMS regulations
  • Networks with other hospitals locally and nationally to build understanding of standards and identify best practices
  • Maintains current knowledge of other regulatory agencies including OSHA, Life Safety Code, EMTLA, HIPAA, etc
• Facilitates and/or participates in various teams and committees as appropriate to support specific improvement efforts and continual readiness
  • Participates in the standardization of policy development and approval processes throughout the organization
  • Participates on appropriate teams in which expertise of TJC standards and CMS regulations are required
  • Facilitates process improvement teams as needed
  • Works collaboratively with other departments and functions to develop an integrated approach to patient safety
  • Participates in the organizational policy review process through the Accreditation chapter structure
  • Serve as Policy Committee member and supports process for review of all policies at least every four years
  • Reviews policies as a key stakeholder to provide feedback regarding standards interpretation
  • Participates in the approval process with new, revised or achieved policies

QUALIFICATIONS

Minimum Qualifications:

• Bachelor's degree in related healthcare field. Master's degree preferred
• Graduation from an accredited school of nursing preferred
• Three (3) years' experience working with regulatory agencies such as The Joint Commission or CMS on survey preparation
• Four (4) years' experience working in an acute hospital setting

-OR-

• An approved equivalent combination of education and experience

Knowledge/ Skills/ Abilities:

• Knowledge of The Joint Commission and CMS regulatory requirements
• Analysis, communication, presentation, prioritization, and problem-solving skills
• Measurement, data gathering, and interpretation experience
• Knowledge of patient care standards
• Performance improvement principles and methods experience
• Attention to detail and ability to work with complex processes

License/Certifications:

• If incumbent is a Registered Nurse, possession of a valid license, or a permit to practice, issued by the State of Minnesota Board of Nursing is required

You've made the right choice in considering Hennepin Healthcare for your employment. We offer a wealth of opportunities for individuals who want to make an impact in our patients' lives. We are dedicated to providing Equal Employment Opportunities to both current and prospective employees. We are driven to connect talented individuals with life-changing career opportunities, enabling you to provide exceptional care without exception. Thank you for considering Hennepin Healthcare as a future employer.

Please Note: Offers of employment from Hennepin Healthcare are conditional and contingent upon successful clearance of all background checks and pre-employment requirements.

• We offer a competitive pay rate based on your skills, licensure/certifications, education, experience related to this position, and internal equity.
• We provide an extensive benefits program that includes Medical; Dental; Vision; Life, Short and Long-term Term Disability Insurance; Retirement Funds; Paid Time Off; Tuition reimbursement; and license and Certification reimbursement (Available ONLY for benefit eligible positions).
• For a complete list of our benefits, please visit our career site on why you should work for us.