Currently looking for an experienced healthcare leader to fill the Assistant Director of Accreditation and Regulatory Compliance opening at Lucile Packard Children's Hospital at Stanford. The Assistant Director will serve as a leader and member of the Center for Quality & Clinical Effectiveness.

Responsibilities of the Assistant Director, Accreditation & Regulatory Compliance

  • Assists the Director of Accreditation & Regulatory Compliance to ensure that all Lucile Packard Children's Hospital's (LPCH) operations comply with state and federal regulations as well as accreditation standards and requirements of a Medical Center designated to the care of infants, children, adolescents and pregnant women.
  • Responsible for regulatory compliance for all off-site and outpatient clinics and maintaining organizational readiness and compliance to ensure that LPCH standards, policies, procedures and  practices are  consistent with state and federal regulations as well as Joint Commission requirements.
  • Responsible for leading and monitoring assigned performance improvement projects; survey readiness, education and mock surveys; redesign care delivery processes; and ensure all projects yield sustained improvement. 
  • Serves as a member of the department's leadership team by participating in strategic planning and other key areas. Serves as back-up in the absence of department director.
  • Assesses and evaluates impact  and  effectiveness of changes on regulatory and accreditation initiatives, plans, and programs.
  • Assists Director of Accreditation & Regulatory Compliance to partner with Center for Quality and  Clinical Effectiveness Medical Director and Administrative Director to incorporate peer review  and  regulatory agency findings into the Centers strategic plan.
  • Assists in developing strategic initiatives, procedures, and  processes for clinical regulatory and  accreditation compliance.
  • Develops new policies  and  procedures and/or oversees policy and  procedure development; Updates and makes revision  as necessary of policies  and  procedures to comply with accreditation and  regulatory standards and  requirements.
  • Ensures compliance with Medical Staff standards as required by regulatory agencies.
  • Ensures communication occurs to relevant departments, committees, and staff including Care Improvement Committee, medical staff, and quality improvement committees.
  • Evaluates and  analyzes proposed clinical activities for applicability and compliance with Federal, State, and other  regulatory agency requirements.
  • Gathers and analyzes clinical and  financial information from a variety of internal and external sources relating to regulatory and accreditation compliance, utilization of resources, physician practice patterns, system problems, and other quality functions. Identifies trends, variances, deficiencies, and problems utilizing aggregated data and information.
  • Mentors and acts as advisor to Quality Manager and other staff with respect to accreditation and regulatory compliance.
  • Participates in comprehensive regulatory and accreditation assessments and evaluations of specific  clinical activities for effectiveness and recommends strategic systems, programs, and alternatives for identified deficiencies and problems
  • Participates in or leads work groups in special projects as assigned.
  • Participates in the development and implementation of regulatory and accreditation activities by facilitating interdisciplinary collaboration of caregivers.
  • Participates with department management in the development and implementation of department policies and procedures and departmental regulatory, accreditation and performance improvement initiatives.
  • Leads development of processes and maintenance of V-Survey, including maximizing the information collected during tracers to proactively improve systems and processes and mitigate risks to patient safety, accreditation and compliance.

Requirements of the Assistant Director, Accreditation & Regulatory Compliance

  • Education: Bachelor’s degree in a work-related discipline/field from an accredited college or university.
  • Experience: Five (5) years of experience demonstrating progressively more responsibility in the regulatory and accreditation area.
  • Knowledge of principles and  practices of organization, administration, fiscal and  personnel management Knowledge of principles and  practices of strategic planning, quality improvement, program evaluation, hospital administration and  healthcare financial management.
  • Knowledge of state and  federal regulatory requirements related to healthcare compliance.
  • Knowledge of statistical analysis and  reporting practices pertaining to quality improvement and program.

This is a management position
This is a full-time position

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