Details
Posted: 27-Apr-22
Location: Durham, North Carolina
Salary: Open
Duke University Hospital is consistently rated as one of the best in the United States and is known around the world for its outstanding care and groundbreaking research. Duke University Hospital has 957 inpatient beds and offers comprehensive diagnostic and therapeutic facilities, including a regional emergency/trauma center; a major surgery suite containing 51 operating rooms; an endo-surgery center; an Ambulatory Surgery Center with nine operating rooms and an extensive diagnostic and interventional radiology area. In fiscal year 2018, Duke University Hospital admitted 42,916 patients and had 1,085,740 outpatient visits in fiscal year 2017.
U.S News & World Report named Duke University Hospital #1 in North Carolina and #1 in the Raleigh-Durham area in 2018-19.
Duke University Hospital is ranked in the top 20 nationally for seven adult specialties, including cardiology and heart surgery, nephrology, ophthalmology, orthopedics, pulmonology, rheumatology, and urology.
In addition to its hospitals, Duke Health has an extensive, geographically dispersed network of outpatient facilities that include primary care offices, urgent care centers, multi-specialty clinics and outpatient surgery centers.
General Description:
Responsible for supervision, oversight and monitoring of the hospital's compliance with, state, federal and local regulatory requirements and all accreditation/certification standards such as The Joint Commission, CMS, and North Carolina Division of Health Service and Regulation (DHSR). Establishes a quality assurance system to ensure procedures and protocols are consistent with requirements to achieve constant readiness for regulatory site visits and surveys in collaboration with senior management.
Duties and Responsibilities:
Provides leadership in the development and implementation of strategies regarding regulatory compliance.
Directs and coordinates accreditation, policy, and regulatory affairs initiatives for the Hospital; serves as the organizational liaison with Joint Commission, DHRS and other pertinent agencies.
Analyzes, interprets and makes recommendations to meet federal, state and local requirements. Establishes mechanisms for proactive identification of regulatory issues and tracking of corrective actions.
Assesses compliance with accreditation standards and regulations. Identifies key accreditation, regulation and licensing issues and defines areas for improvement. Collaborates with department management and hospital leaders.
Develops and monitors actions to address individual and aggregate trends to ensure adherence to all regulatory requirements. Evaluates effectiveness of corrective actions for identified problems and continuous quality improvement activities.
Collaborates with the Patient Safety Officer on root cause analysis of sentinel events to ensure compliance with Joint Commission framework.
Works with the Accreditation staff to investigate and respond to Joint Commission Complaints. Collaborates with Risk Management as appropriate.
Monitors for and communicates changes in federal and state regulations and Joint Commission accreditation standards to hospital leadership and staff. Develops and updates policies and procedures as needed to remain in compliance. Responsible for the flow of policies and once approved posts on the DUHS intranet website.
Leads and participates in relevant DUH and DUHS committees such as Continual Readiness Committee and Performance Improvement Oversight Committee. Establishes other relevant committees as appropriate to ensure continual readiness.
Supervises the Accreditation staff and other staff responsible for coordinating compliance with accreditation and regulatory standards.
Financially responsible for Accreditation department and programs.
Coordinates quality reviews, identifies resources needed, people to be involved, and the logistics of accomplishing the project.
Provides in-services and continuing education for leadership and staff.
Responsible for the flow of DUH policies and once approved posts on the DUHS intranet website.
Participates in State and Federal quality improvement projects to obtain comparative data on quality indicators, to use in assessing how well the institution is doing in relation to others and compliance with the Joint Commission standards.
Serves as the representative for external interactions with accrediting and regulatory bodies.
Performs other duties as assigned.
Required Qualifications at this Level:
Education
Bachelor's degree required.
Experience
Seven years of experience in healthcare regulatory and auditing activities required.
A Master's degree in Hospital Administration, Business Administration or a related field may be substituted for experience on a 1:1 basis.
Licensure or Certification
Highly preferred - Registered Nurse or other Clinical Professional with current licensure/certification preferred.
Knowledge, Skills, and Abilities
Knowledge of state and federal regulations, and the Joint Commission standards and practices for acute care hospitals is required.
Must demonstrate a broad-based knowledge of and an ability to coach implementation of total quality management in the hospital.
Knowledge of quality improvement and risk management.
Highly effective verbal and written communication skills are necessary to work with medical, nursing staff and external review agencies in monitoring and evaluating the quality of patient care.
Demonstrated ability to collaborate with multiple members of the health care and administrative leadership team.
Demonstrated ability to think critically, develop conceptual strategies.
Essential Physical Job Functions:
Requires the ability to sit or stand for long periods of time, occasional stooping, and reaching; May require lifting up to 25 pounds; requires a normal range of vision and hearing with or without accommodations.
General Description:
Responsible for supervision, oversight and monitoring of the hospital's compliance with, state, federal and local regulatory requirements and all accreditation/certification standards such as The Joint Commission, CMS, and North Carolina Division of Health Service and Regulation (DHSR). Establishes a quality assurance system to ensure procedures and protocols are consistent with requirements to achieve constant readiness for regulatory site visits and surveys in collaboration with senior management.
Duties and Responsibilities:
Provides leadership in the development and implementation of strategies regarding regulatory compliance.
Directs and coordinates accreditation, policy, and regulatory affairs initiatives for the Hospital; serves as the organizational liaison with Joint Commission, DHRS and other pertinent agencies.
Analyzes, interprets and makes recommendations to meet federal, state and local requirements. Establishes mechanisms for proactive identification of regulatory issues and tracking of corrective actions.
Assesses compliance with accreditation standards and regulations. Identifies key accreditation, regulation and licensing issues and defines areas for improvement. Collaborates with department management and hospital leaders.
Develops and monitors actions to address individual and aggregate trends to ensure adherence to all regulatory requirements. Evaluates effectiveness of corrective actions for identified problems and continuous quality improvement activities.
Collaborates with the Patient Safety Officer on root cause analysis of sentinel events to ensure compliance with Joint Commission framework.
Works with the Accreditation staff to investigate and respond to Joint Commission Complaints. Collaborates with Risk Management as appropriate.
Monitors for and communicates changes in federal and state regulations and Joint Commission accreditation standards to hospital leadership and staff. Develops and updates policies and procedures as needed to remain in compliance. Responsible for the flow of policies and once approved posts on the DUHS intranet website.
Leads and participates in relevant DUH and DUHS committees such as Continual Readiness Committee and Performance Improvement Oversight Committee. Establishes other relevant committees as appropriate to ensure continual readiness.
Supervises the Accreditation staff and other staff responsible for coordinating compliance with accreditation and regulatory standards.
Financially responsible for Accreditation department and programs.
Coordinates quality reviews, identifies resources needed, people to be involved, and the logistics of accomplishing the project.
Provides in-services and continuing education for leadership and staff.
Responsible for the flow of DUH policies and once approved posts on the DUHS intranet website.
Participates in State and Federal quality improvement projects to obtain comparative data on quality indicators, to use in assessing how well the institution is doing in relation to others and compliance with the Joint Commission standards.
Serves as the representative for external interactions with accrediting and regulatory bodies.
Performs other duties as assigned.
Required Qualifications at this Level:
Education
Bachelor's degree required.
Experience
Seven years of experience in healthcare regulatory and auditing activities required.
A Master's degree in Hospital Administration, Business Administration or a related field may be substituted for experience on a 1:1 basis.
Licensure or Certification
Registered Nurse or other Clinical Professional with current licensure/certification preferred.
Knowledge, Skills, and Abilities
Knowledge of state and federal regulations, and the Joint Commission standards and practices for acute care hospitals is required.
Must demonstrate a broad-based knowledge of and an ability to coach implementation of total quality management in the hospital.
Knowledge of quality improvement and risk management.
Highly effective verbal and written communication skills are necessary to work with medical, nursing staff and external review agencies in monitoring and evaluating the quality of patient care.
Demonstrated ability to collaborate with multiple members of the health care and administrative leadership team.
Demonstrated ability to think critically, develop conceptual strategies.
Essential Physical Job Functions:
Requires the ability to sit or stand for long periods of time, occasional stooping, and reaching; May require lifting up to 25 pounds; requires a normal range of vision and hearing with or without accommodations.
Duke is an Affirmative Action/Equal Opportunity Employer committed to providing employment opportunity without regard to an individual's age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, sex, sexual orientation, or veteran status.
Duke aspires to create a community built on collaboration, innovation, creativity, and belonging. Our collective success depends on the robust exchange of ideas—an exchange that is best when the rich diversity of our perspectives, backgrounds, and experiences flourishes. To achieve this exchange, it is essential that all members of the community feel secure and welcome, that the contributions of all individuals are respected, and that all voices are heard. All members of our community have a responsibility to uphold these values.
Essential Physical Job Functions: Certain jobs at Duke University and Duke University Health System may include essentialjob functions that require specific physical and/or mental abilities. Additional information and provision for requests for reasonable accommodation will be provided by each hiring department.
