Regional Dir-Accreditation and Licensure

York, PA | Professional | Tracking Code: 66429

Job Description:

Under the general supervision of the Director-WSH Accreditation and Licensure, provides regional leadership and oversight for the accreditation and licensure activities at the other hospitals based in the assigned WellSpan Region. Provides direction and leadership by coordinating activities designed to achieve and maintain compliance with the PA Department of Health, hospital accreditation organizations, CMS Conditions of Participation and the Department of Human Services regulations (accreditation standards) directly for the Hospital and for all outpatient centers/practices that are licensed by the Hospital. Performs a variety of clinical audits, analysis of the data as well as ensures compliance with regulatory audits. Acts as Coordinator for on-site surveys and works in collaboration with others to facilitate system process and outcome improvements. Working with clinical teams and facilities staff, determines root cause for identified defects and deficiencies and prepares standard work and policy recommendations as appropriate. Spreads information through communication forums such as WellSpan’s Quality Leadership Team (QLT) and Accreditation Leadership Team (ALT).

 

Duties and Responsibilities

 

  1. Ensures that all standards related to licensure and hospital accreditation standards are being met.
  2. Works closely with leadership and appropriate staff to coordinate survey follow-up activities, including plans of action, monitoring systems, clarifications and challenges.
  3. Keeps abreast of appropriate regulatory agency requirements related to accreditation and licensure.
  4. Educates others in interpretation of standards and assists as needed in planning improvements/compliance.
  5. Initiates mock tracers as well as analyzing the data, reporting results to the appropriate oversight committee(s), and plans intervention activities for improvement, as appropriate.
  6. Facilitates the Survey Readiness Committee and related activities.
  7. Compiles data for and prepares regularly scheduled or special reports, analyses and statements.
  8. Develops and oversees the implementation of corrective action plans to address survey findings.
  9. Keeps abreast of appropriate regulatory agency requirements related to accreditation.
  10. Utilizes findings to initiate improvement. Utilizes Tracer activities as educational opportunity for staff.
  11. Serves as local resource for clinical risk management activities and as liaison with WellSpan Health System Risk Management staff.
  12. Provides ongoing reports and updates of existing and potential regulatory compliance issues to the DAL, Senior leadership, hospital Board(s) and other individuals and groups as directed. 13 Knowledgeable about Lean methodologies and uses Lean Daily Management System tools to implement effective process improvements.
  13. Active participant in the Hospital Environmental Safety Committee, Emergency Management Committee, and Environment of Care Rounds. 15Coordinates and disseminates information to all hospital employees regarding accreditation and licensure, providing educational guidance as appropriate.
  14. Develops, establishes and implements goals, objectives, and policies and procedures for department and hospital operations, which guide and support the provision of services.
  15. Continuously assesses and improves the department, entity’s performance. Maintains appropriate quality control/assessment programs (if applicable).
 

Qualifications

  • Notes:
    • Other combinations of formal education, training and experience may be considered.

 

  • Minimum Experience:
    • 5 years
    • Min Field of ExpertiseGovernment Regulations; Healthcare and Regulatory Affairs; clinical experience related to Patient Safety

 

  • Minimum Education:
    • Master’s Degree in a related field such as Healthcare Administration

 

  • Required Certification:
    • istrationCurrent and active RN license in PA preferred; other clinical experience considered; HACP and CJCP are preferred

 

  • Skills:
    • Skills of Lean methodologies preferred, Demonstrated leadership skills and ability to work independently; Demonstrated knowledge of health care and regulatory affairs; Must have a global view of the WellSpan Health vision and mission; Needs to be analytical, inquisitive, persistent and detail-minded; Must possess a work ethic that is fair, moral, objective and discreet; Project management and computer skills are required.
James Kane
James Kane
Sr. Talent Acquisition Consultant
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Why WellSpan Health?

WellSpan Health is an integrated health system that serves the communities of central Pennsylvania and northern Maryland. The organization comprises a multispecialty medical group of more than 1,600 physicians and advanced practice providers, a regional behavioral health organization, a home care organization, eight respected hospitals, more than 20,000 employees and 200 patient care locations. WellSpan is a charitable, mission-driven organization committed to exceptional care for all, lifelong wellness and healthy communities. We are committed to transforming the health of the communities we serve and to educating the next generation of clinicians, staff and leaders.

Employment Benefits

  • Sign-on incentives for new employees (click here for details)
  • Medical, dental and vision insurance
  • Life and accidental death insurance
  • Supplemental life insurance
  • Retirement savings plan
  • Paid time off (PTO)
  • PTO bridging
  • Short-term disability
  • Educational assistance
  • Forgivable loan
  • Flexible spending
  • Credit union
  • Employee recreational activities
  • Childcare
  • Complimentary medicine discounts

Diversity & Inclusion

Welcome. Respect. Value.

Wellspan Health believes that diversity includes all the human characteristics that make each of us similar as well as different. We strive to make every person feel welcomed, respected, and valued while creating a safe and inclusive environment where we all have the individual freedom to express our uniqueness in a respectful manner.

WellSpan Health is an equal opportunity employer. Employment selection and related decisions are made without regard to sex, race, age, disability, religion, national origin, color or any other protected class. WellSpan Health does, however, have a tobacco-free/nicotine-free hiring policy.

Quality of Life

Founded in 1741, the city of York is considered by many as the first capital of the United States. The Articles of Confederation were signed by the Second Continental Congress here in 1777. Its beautifully restored historic district is an architectural treasure. While York retains its farming and manufacturing heritage, at its heart York is a thriving cultural community that has attracted creative talent and innovative entrepreneurial investors from across the nation.

Life in York County offers affordable housing, options for higher education, a thriving arts and cultural community, historical attractions, parks and recreational resources, semi-professional baseball team, fine dining and more — within an easy drive of major East Coast cities.

York County residents can find local employment in healthcare, manufacturing, technology, agricultural and service sectors. (Patient population: 445,000)