Job Profile Summary
The Manager, Accreditation & Regulatory works with the Director, Quality & Patient Safety, as well as the Chief Medical Officer to provide Medical Center expertise on accreditation and regulatory standards required by accrediting bodies such as The Joint Commission, or regulators such as Massachusetts Department of Public Health and Center for Medicare and Medicaid Services. This position plays a management role in the improvement in systems needed to provide safe, effective, efficient, patient-centered, equitable, and timely health care to the patients served by Boston Medical Center Brighton.
Job Description

POSITION SUMMARY:

The Manager, Accreditation & Regulatory works with the Director, Quality & Patient Safety, as well as the Chief Medical Officer to provide hospital leadership on accreditation and regulatory standards required by accrediting bodies such as The Joint Commission, or regulators such as Massachusetts Department of Public Health and Center for Medicare and Medicaid Services. This position plays a management role in the improvement in systems needed to provide safe, effective, efficient, patient-centered, equitable, and timely health care to the patients served by Boston Medical Center Brighton.

EDUCATION:

Baccalaureate Degree in nursing required.

Collaborates with departmental administrators and clinical staff to share knowledge, articulate expectations, and evaluate the effectiveness of the medical center and oversight locations regulatory planning and response activities.

• Provides education and consultation to administrative and clinical leadership, staff and faculty at BMCB regarding the requirements of accreditation and regulatory organizations, using both formal and informal venues, e.g. presentations, publications, email, computer-based methods

ESSENTIAL RESPONSIBILITIES / DUTIES:

Manages the development, implementation, and maintenance of a comprehensive and collaborative medical center Accreditation & Regulatory program to ensure continual readiness at the BMCB facility that:

• Is compliant with all standards and regulations required by accrediting bodies and regulators.
• Is benchmarked to reflect the current state of knowledge, processes, and best practices related to hospital and behavioral health accreditation and regulatory matters.
• Is compliant with current industry, national, regional, and local regulations, standards, and guidelines.
• Provides guidance and assistance to BMCB licensed offsite locations regarding improvements needed to ensure compliance with accreditations standards and regulatory requirements.
• Provides timely communication regarding new and revised accreditation standards/regulations and interpretations to administrative and clinical leadership, staff and faculty.

Serves as the BMCB expert for accreditation standards, regulations and conditions of participation. Responsible for the interpretation and communication of regulatory and licensing requirements at BMCB.
Develops and maintains effective working relationships with accreditation and regulatory agencies and surveyors. Serves and the primary point of contact and liaison with internal and external public health and safety representatives in preparing for accreditation/survey, assuring that plans are properly integrated and coordinated with the plans of BMCB.

Collaborates with departmental administrators and clinical staff to share knowledge, articulate expectations, and evaluate the effectiveness of the medical center and oversight locations regulatory planning and response activities.

• Provides education and consultation to administrative and clinical leadership, staff and faculty at BMCB regarding the requirements of accreditation and regulatory organizations, using both formal and informal venues, e.g. presentations, publications, email, computer-based methods.

Provides management and oversight of post-action review and development of improvement plans following each accrediting or regulatory site visit.
Provides management and oversight of staff and workgroups, providing guidance and direction for planning activities and program maintenance.
Manages ongoing efforts to assess vulnerability and risk assessments that allow for the identification of issues with appropriate corrective action plans.
Develops and presents program process improvement reports as requested and appropriate to division and institutional leadership meetings, as appropriate.
Builds effective, supportive, productive relationships with leadership, staff and faculty throughout BMCB and oversight facilities.
Facilitates the development of tools, policies, and procedures, and learning aids to promote compliance with standards and regulations.
Responsible for ensuring preparation of reports assessing institutional, department, section, program and unit compliance with accreditation and regulatory requirements.
Leads a coordinated response to unannounced external accrediting or regulatory agency visits.
Facilitates accrediting and regulatory steering committee(s) and other committees as needed.
Responsible for overseeing and supporting the BMCB policy and procedure system including membership to the Policy and Procedure Roundtable.
Serves as a member of the Quality and Patient Safety Committee(s) and other committees as deemed appropriate.
Works with Risk Management on an as-need basis to support BORM and DPH requirements regarding reporting of adverse events and onsite complaint surveys.
Must adhere to all of BMC’s RESPECT behavioral standards.
Other duties as directed.