"Administrative Director Accreditation"

A cover letter is required for consideration for this position and should be attached as the first page of your resume. The cover letter should address your specific interest in the position and outline skills and experience that directly relate to this position.

The Office of Accreditation and Regulatory Readiness at the University of Michigan Health - Academic Medical Center (UMH-AMC) is seeking a proven leader to fill the role of Director of Accreditation and Regulatory Readiness. This position will be part of the Quality Department. The Accreditation and Regulatory Readiness Director is responsible for collaborating with UMH-AMC staff and medical staff to provide a proactive and unified perspective and understanding of accreditation, regulatory, and disease specific certification requirements and activities. The Accreditation and Regulatory Director is a systems thinker who plays a pivotal role in leading organizational efforts to achieve the highest compliance with accreditation and certification standards, ensuring practices not only meet but also exceed benchmarks for patient care excellence.

The Director is responsible for leading the Accreditation and Regulatory Readiness team. The Director proactively assesses regulatory risks and develops plans to address these risks. The Director regularly updates UMH-AMC leadership on the status of readiness and barriers encountered in addressing risks.

The Director collaborates with other UMH leaders in Operations, the Department of Nursing, Corporate Compliance, the Office of General Counsel, Patient Safety, Patient Relations & Clinical Risk, Supply Chain, Ambulatory Care, and other areas to prepare for and respond to regulatory surveys and actions. The Director and their team coordinate Health System responses to regulatory surveys and actions.

Accreditation and Regulatory Compliance: (45%)

• Provides leadership and consultation in all aspects of external accreditation and regulation as it relates to compliance with the Joint Commission on Accreditation of Healthcare Organizations (JC), the Centers for Medicare and Medicaid Services (CMS), the U.S Food and Drug Administration (FDA) Good Tissue, and other related accreditation and regulatory agencies.
• Proactively designs, develops, evaluates, and implements the UMH-AMC Continuous Accreditation and Regulatory Readiness program. Activities related to this program include: Internal Continuous Readiness self-surveys and mock validation surveys, use of Patient Tracer methodology, JC/CMS/FDA Education and Training, Communication of regulatory readiness and risks as well as external regulatory body survey results and required action plans to Management/Senior Leadership, all duties related to JC Application, Intracycle Monitoring and other regulatory body periodic survey processes, reports, and action plan follow up.
• Collaborates with Patient Safety, Quality, Corporate Compliance, Office of General Council, Patient Relations & Clinical Risk to ensure regulatory functions are assessed and in compliance with standards.
• Maintains a thorough understanding of various external accreditation standards, rating systems, and decision-making processes to ensure UMH-AMC’s continual readiness and compliance. Stays up to date on current and developing regulatory and accreditation standards.
• Leads the UMH-AMC Accreditation and Regulatory Readiness Council.
• Leads and prepares the team to respond to accreditation and regulatory surveys and actions. Designs, implements, and evaluates the internal readiness plan to assess the UMH-AMC performance related to all applicable accreditation and regulatory requirements (e.g., standards, conditions of participation).

Performance Improvement and Policy Integration: (20%)

• Collaborates with department leaders and quality teams to drive corrective actions and ensure timely resolution of identified deficiencies or citations.
• Utilizes quality and process improvement methodologies, including High Reliability tools to facilitate process changes.
• Manages, guides, and supports policy work across UMH-AMC. Conducts ongoing review of policies, procedures, and practices to ensure alignment with current standards. Supports operational leaders in developing, reviewing, and updating policies and procedures as needed to ensure compliance with accreditation, certifications, and regulatory requirements.

Leads and manages the operations of the Accreditation and Regulatory Program: (20%)

• Provide leadership and expertise through leveraging the knowledge and skills of staff.
• Manage daily operations and workflow of staff, ensuring balanced workloads and effective cross-training. Interview, hire, promote, train, and discipline staff as needed.
• Develop and maintain a work environment that fosters continuous self-learning, reflection, feeling of ownership and demonstration of responsibility and accountability.
• Promote staff development, providing appropriate support for their self-development goals.

Documentation and Reporting: (10%)

• Coordinates the development, implementation, follow-up, and evaluation of corrective action plans in response to external accreditation bodies' citations and identified areas for improvement. Timely completion of all required reports to applicable accreditation and regulatory agencies.
• Coordinates the implementation of the readiness plan and provides formal executive leadership updates and written reports for local area/unit leadership and appropriate line leadership.
• Maintains all required documentation for regulatory bodies, including Plans of Correction, Statement of Deficiency, and periodic self-assessment
• Maintains accurate and up-to-date information in the UMH-AMC accreditation readiness data management system, including contributing to the collection, recording, and integrity of data to ensure accurate reporting and analysis of accreditation processes, dashboard measures, and monthly statistics.
• Tracks and reports on accreditation metrics and readiness indicators to executive leadership.

Education and Training: (5%)

• Develops, implements, and evaluates educational programs, events, and communication to maintain organizational readiness at all levels of staff.
• Provides support to other departments with department specific educational efforts as applicable.

Other duties as assigned.

Required Qualifications

• Bachelor's degree in a healthcare field, e.g., Healthcare Administration, Nursing, or Business Administration
• A minimum of five (5) years' experience successfully leading or substantively participating in a health system(s) accreditation readiness preparation program.
• In-depth knowledge of all health care external regulatory body accreditation standards required (JC, CMS, FDA).
• A minimum of 5 years of management experience is required.
• A minimum of 5 years of financial experience, including some experience with budgeting.
• Must be able to work on-site to ensure readiness for unannounced surveys.
• Excellent written and verbal communication skills.
• Experience with successful change management efforts.

Desired Qualifications

• Master's degree in a healthcare field, e.g., Healthcare Administration, Nursing, or Business Administration
• Eight (8) years of health care compliance and regulatory activities desired.
• Eight (8) plus years of management experience desired.
• Lean or Six Sigma training/certification and experience with applying lean concepts in planning and operations analysis.
• Experience with project management systems, auditing/data analytics, staff training, and creative problems solving.
• Preferred Regulatory/Accreditation or Healthcare Quality Certification: Healthcare Accreditation Certification Program (HACP) or Certified Professional in Healthcare Quality (CPHQ)