In collaboration with the Senior Director of Regulatory Affairs, the Director of Accreditation plans, implements, directs and facilitates activities that support Cleveland Clinic's ability to achieve and remain a successfully accredited heath care organization that is continuously ready for patients every day. This includes, but is not limited to, serving as the on-site survey leader, as a resource and consultant to the organization, as a liaison between Cleveland Clinic and its accreditation or regulatory bodies, and as an expert in continuous improvement activities. Responsible for the organization, coordination and administration of accreditation survey activities before, during and after survey. The scope includes Cleveland Clinic Main Campus and associated Family Health Centers, Ambulatory Surgery Centers, Emergency Departments and physician practices. Regulatory/accrediting agencies include, but are not limited to The Joint Commission (TJC), Centers for Medicare and Medicaid Services (CMS), Ohio Department of Health (ODH). Duties may include participation in enterprise activities as directed by the Sr. Director, Regulatory Affairs.
Effectively directs activities related to TJC including application submission, survey planning and logistics, post-survey Evidence of Standards Compliance (ESC) and annual intercycle monitoring.
Directs continuous readiness activities including Continuous Readiness Rounds, Tracer Teams, Mock Surveys, Intranet Accreditation site content, and educational materials and activities.
Leads and Coordinates regulatory on-site surveys, including but not limited to TJC, ODH and CMS.
Responsible for effective post survey action plans and formal responses to accrediting and regulatory agencies.
Maintains current knowledge of accreditation and compliance issues affecting healthcare.
Stays abreast of changes in TJC standards, Ohio Administrative Code and Ohio Regulatory Code, CMS Conditions for Coverage and Conditions of Participation requirements and standards.
Communicate standard changes to executive leadership and others in the organization who need to know.
Collaborates with Enterprise Quality Departments and organization Institutes to ensure Cleveland Clinic is compliant with accreditation standards and regulatory requirements.
Other duties as assigned.
Bachelor’s Degree in health-related field required.
Master’s Degree preferred.
Certifications required: Healthcare Accreditation Certified Professional (HACP) or Certified Joint Commission Professional (CJCP).
If applicant does not have one of these certifications, they will need to achieve certification within 1 year.
COMPETENCIES (COMPLEXITY OF WORK):
In-depth knowledge of accrediting and regulatory standards with demonstrated ability to interpret standards, serve as a subject matter expert and communicate information to all levels in the organization.
Demonstrated leadership skills with the ability to manage employees and prioritize and manage multiple tasks simultaneously.
Excellent communication skills to effectively interact with all levels of Caregivers, from senior leaders to front-line caregivers.
Minimum ten years health care experience in a clinical discipline including at least five years accreditation experience and 5 years leadership/management experience.
Specific experience related to accreditation and regulatory bodies, such as CMS and state licensing agencies.
Manual dexterity to operate office equipment
Ability to lift and transport up to 15 pounds
Requires extended periods of standing, walking and sitting.
Normal or corrected vision and hearing to normal range.
PERSONAL PROTECTIVE EQUIPMENT:
Donning and doffing appropriate PPE when performing tracers or visiting patient care areas.