Summary:

In a High Reliability Organization, the Program Director Regulatory and Accreditation provides leadership and direction for regulatory and accreditation for CHRISTUS Health. Directs organization-wide processes for evaluating, monitoring, and improving compliance with internal and external requirements. Standardizes the organization's processes to prepare for, participate in and follow up on regulatory, accreditation and certification surveys and activities. Serves as a consultant to executive officers and directors to review and comment on the regulatory effect of new initiatives, evaluate organizational processes and work with individuals at all levels of the organization to implement change. Provides guidance on the corrective action plans developed by leaders from areas that were cited. Develops the frameworks and evaluation methods for continuous readiness programs for all aspects of CHRISTUS. Provides coaching of members of the leadership team on regulatory preparedness. Works closely with senior leaders to develop improvements in the organization. Ensures that key executive leaders are kept informed of survey progress and issues across the organization. Evaluates the entire process and ensure that the ongoing monitoring addresses the issues that were cited without causing new areas of noncompliance downstream. Communicate the results of the survey and ramifications of the findings to individuals at all levels of the organization. Knowledgeable on agencies such as Joint Commission and CMS. assists in policy implementation for processes and programs facilitating regulatory and accreditation compliance with federal and state laws and regulations. Additionally, the Program Director assists in policy implementation for processes and programs facilitating regulatory and accreditation compliance with federal and state laws and regulations. 

• Quality Leadership and Integration-Advance the organization's commitment to health care quality through collaboration, learning opportunities and communication. Lead the integration of quality into the fabric of the organization through a coordinated infrastructure to achieve organizational objectives. Domain Level: Advanced.
• Performance and Process Improvement-Use performance and process improvement (PPI), project management and change management methods to support operational and clinical quality initiatives, improved performance and achieve organizational goals. Domain Level: Advanced.
• Population Health and Care Transitions-Evaluates and improve health care processes and care transitions to advance the efficient, effective, and safe care of defined populations. Domain Level: Proficient
• Health Data and Analytics- Leverage the organizations analytic environment to help guide data-driven decision-making and inform quality improvement initiatives. Domain Level: Advanced
• Regulatory and Accreditation-Direct organization wide processes for evaluating, monitoring, and improving compliance with internal and external requirements. Lead the organization's processes to prepare for, participate in, and follow up on regulatory, accreditation and certification surveys and activities. Domain Level: Advanced
• Patients Safety-Cultivate a safe healthcare environment by promoting safe practices, nurturing a just culture, and improving processes that detect, mitigate, or prevent harm. Domain Level: Advanced
• Quality Review and Accountability-Direct activities that support compliance with organization wide voluntary, mandatory, and contractual requirements for data acquisition, analysis, reporting, and improvement. Domain Level: Advanced
• Professional Engagement-Engage in the healthcare quality profession with a commitment to practicing ethically, enhancing one's competence, and advancing the field. Domain Level: Proficient

Requirements:

Work Type:

Full Time

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About CHRISTUS Health

CHRISTUS HEALTH is an international Catholic, faith-based, not-for-profit health system comprised of almost more than 600 services and facilities, including more than 60 hospitals and long-term care facilities, 350 clinics and outpatient centers, and dozens of other health ministries and ventures. CHRISTUS operates in 6 U.S. states, Colombia, Chile and 6 states in Mexico. To support our health care ministry, CHRISTUS Health employs approximately 45,000 Associates and has more than 15,000 physicians on medical staffs who provide care and support for patients. CHRISTUS Health is listed among the top ten largest Catholic health systems in the United States.

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