1. Provide oversight and direction to endure that UM Capital meets regulatory requirement mandated by Joint Commission accreditation, CMS Conditions of Participation, OSHA, and state and federal regulations.

Assume management responsibility over all accreditation and regulatory functions ensuring safe care and compliance.
Serve as an expert resource on accreditation and regulatory issues for UM Capital staff, physicians and leadership.
Maintain current awareness of state, federal and national regulations required to maintain accreditation and/or certification for all areas of UM Capital.
Ensure timely completion and oversee the completion of ongoing self-assessments for standard compliance for the annual Joint Commission Periodic Performance Review and Measures of Success.
Prepare reports and evaluate progress regarding status of compliance for improvements and deficiencies identified by regulatory deficiencies.
Submit timely reports to the regulatory entities related to action plans as well as follow up for areas in need of improvement.
Serve as the system representative for external interaction with accreditation and regulatory entities

2. Provide leadership in the development and implementation of strategies regarding continuous regulatory readiness, education of the regulatory standards and revise education as standards change.

Coordinate and facilitate the Continuous Survey Readiness Committee and ensure Chapter Captains are current on all requirements.
Identify areas in which UM Capital does not meet the intent of the standards. Coordinate work groups and/or performance improvement activity to bring the standard in line with the regulations.
Collaborate with UM Capital physicians, coordinators, leaders and executives to address areas of opportunity, identify strategies to improve performance, implement and evaluate corrective actions.
Plan and oversee mock surveys and associated action plans.
Develop strategies to enhance compliance and work with leaders and executives to assure execution.

3. Responsible for regulatory complaint surveys and follow up.

4. Assure policies and procedures are updated as required.

5. Supervise Accreditation personnel

6. Perform other duties as assigned by the Vice President for Quality and Safety

Company Description

The Director is responsible for establishing and maintaining a continuous survey readiness culture for University of Maryland Capital Region Medical Center, Bowie Health Center, Outpatient Centers and Laurel Freestanding Medical Facility. Primary duties include overseeing, educating, monitoring and identifying areas of opportunity to insure compliance with standards for the Joint Commission, Maryland Department of Health & Mental Hygiene, and Centers for Medicare & Medicaid Services (CMS), Maryland Institute for Emergency Medical Services Systems (MIEMSS), Occupational Safety and Health Administration as well as other regulatory institutions as necessary. Achievement of positive survey outcomes and a safe patient environment is the primary goal for the Director of Accreditation. This position reports to the UM Capital Vice President for Quality & Patient Safety. Also acts at the primary liaison for The Joint Commission (TJC).

Qualifications

Required:

Bachelor's degree in nursing or related health science field Master's degree in nursing / health sciences field / MBA or equivalent work experience in the field with advanced education post bachelor's degree. Proficient knowledge of accreditation standards and health care regulations.

Preferred:

Current clinical Licensure in nursing or related healthcare discipline.

Certification in one of the following: CPHQ or CPPS

Additional Information

All your information will be kept confidential according to EEO guidelines.

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About University of Maryland Medical System

The University of Maryland Medical System (UMMS) was created in 1984 when the state-owned University Hospital became a private, nonprofit organization. It has evolved into a multi-hospital system with academic, community and specialty service missions reaching every part of the state and beyond. UMMS is a national and regional referral center for trauma, cancer care, neurocare, cardiac care, women's and children's health and physical rehabilitation. It also has one of the world's largest kidney transplant programs, as well as scores of other programs that improve the physical and mental health of thousands of people daily. The hospitals and health systems that comprise UMMS are: University of Maryland Medical Center, University of Maryland Medical Center Midtown Campus, UM Rehabilitation and Orthopaedic Institute, UM Baltimore Washington Medical Center, UM Capital Region Health, UM Charles Regional Medical Center, UM St. Joseph Medical Center, UM Upper Chesapeake Health, UM Shore Regional Health, Mt. Washington Pediatric Hospital and UM Community Medical Group.

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