Careers in Quality

Quality

1.0 FTE, 8 Hour Day Shift

At Stanford Children's Health, we know world-renowned care begins with world-class caring. That's why we combine advanced technologies and breakthrough discoveries with family-centered care. It's why we provide our caregivers with continuing education and state-of-the-art facilities, like the newly remodeled Lucile Packard Children's Hospital Stanford. And it's why we need caring, committed people on our team - like you. Join us on our mission to heal humanity, one child and family at a time.

Job Summary

This paragraph summarizes the general nature, level and purpose of the job.

The Director of Regulatory and Accreditation Compliance plans, directs, organizes, and improves functions associated with designated Lucile Packard Children's Hospital's (LPCH) operations in order to meet all pertinent regulatory and accreditation requirements of a Medical Center designated to the care of infants, children, adolescents and pregnant women. This position is responsible for 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. The incumbent must be highly skilled in interpretation and application of external regulations and standards in relation to health care delivery in a hospital and clinic setting. The incumbent serves as a central point of contact and resource for multidisciplinary division(s) within the medical center related to matters of accreditation and regulatory affairs.

Essential Functions

The essential functions listed are typical examples of work performed by positions in this job classification. They are not designed to contain or be interpreted as a comprehensive inventory of all duties, tasks, and responsibilities. Employees may also perform other duties as assigned.

Employees must abide by all Joint Commission Requirements including but not limited to sensitivity to cultural diversity, patient care, patient rights and ethical treatment, safety and security of physical environments, emergency management, teamwork, respect for others, participation in ongoing education and training, communication and adherence to safety and quality programs, sustaining compliance with National Patient Safety Goals, and licensure and health screenings.

Must perform all duties and responsibilities in accordance with the hospital's policies and procedures, including its Service Standards and its Code of Conduct.

• Adjusts workload as needed in response to changing needs (e.g., to comply with new laws or regulations requiring rapid implementation of new policies and accompanying complex procedures).

• Assesses training needs; designs and delivers and/or implements in-service training programs for employees to validate competency in best practices required by regulatory or accreditation standards.

• Assumes accountability for the formulation, implementation, and outcomes analysis of accreditation and regulatory-related quality improvement projects; leads and coordinates departmental and interdepartmental problem-solving teams.

• Authors new policies and procedures and/or oversees policy and procedure development; ensures updating and revision as necessary of policies and procedures to comply with accreditation and regulatory standards and requirements.

• Ensures organizational readiness for surveys by all external accreditation and regulatory bodies by developing and maintaining a formal survey readiness plan. Develops and administers a program to prepare all LPCH staff, managers and providers for maintaining a continuous state of compliance and readiness for accreditation and regulatory surveys.

• Ensures that standards, policies and procedures are consistent with standards and requirements as defined by the Joint Commission and other regulatory agencies.

• Fosters and maintains collaborative relationships within the leadership and management of the hospital and clinics, the School of Medicine, medical and patient care staffs, and with external agencies and stakeholders related to peer review, accreditation, and regulatory requirements.

• Identifies, designs and implements new processes, strategies and services to provide a continuous state of regulatory and accreditation readiness.

• In collaboration with clinical staff and services chiefs, participates in the monitoring, reporting, and improvement activities related to peer-review, accreditation, and regulatory requirements.

• Maintains current knowledge and expertise in accreditation standards and regulatory requirements for hospitals, hospital-sponsored ambulatory care, home care and laboratories through continuing education, literature and seminars.

• Monitors service areas, plans approaches for improvement activities, designs new processes, collects and measures data, reviews and reports performance over time, improves and redesigns processes based on the evaluation, and reassess continuously. Fosters, monitors, and implements the concepts of Quality Improvement as it relates to accreditation and regulatory compliance.

• Oversees and manages the Medical Staff Peer Review program, ensuring each medical division/departmental/service line integrates peer review findings into the Hospital Wide Performance Improvement Program. 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. Participates on and supports work teams, work groups, committees (including Regulatory Oversight and Quality Improvement Committee), and provides follow-up for quality initiatives and activities related to the implementation of new standards and ongoing compliance of existing standards.

• Participates on and supports work teams, work groups, committees (including Regulatory Oversight).

• Promotes compliance with legal and regulatory requirements. Conducts mock audits/surveys.

• Provides expert consultative and technical assistance to LPCH departments in preparing for outside surveys.

• Provides leadership and visibility as an LPCH thought leader in national and state regulatory agencies and other quality and safety organizations on a local, state and national level (e.g., NQF, IHI, Joint Commission, Beacon, APIC, ISMP).

• Provides overall direction necessary to ensure that clinical services are provided in accordance with standards established through state and federal regulations and Joint Commission accreditation standards, including the National Patient Safety Goals and that are evidence-based. Identifies areas of vulnerability and directs the development of strategies to enhance compliance.

• Regularly communicates and coordinates/acts as liaison with managers throughout the hospital and outside regulatory and accrediting bodies. Coordinates Joint Commission and other accreditation survey applications, in addition to other required document completion for the Joint Commission.

Minimum Qualifications

Any combination of education and experience that would likely provide the required knowledge, skills and abilities as well as possession of any required licenses or certifications is qualifying.

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.

License/Certification: None

Knowledge, Skills, and Abilities

These are the observable and measurable attributes and skills required to perform successfully the essential functions of the job and are generally demonstrated through qualifying experience, education, or licensure/certification

• Ability to communicate effectively, both orally and in writing.

• Ability to develop and present educational programs and/or workshops.

• Ability to direct the development of programs/processes related to Quality Management and compliance with external regulatory and accreditation standards and requirements.

• Ability to foster effective working relationships and build consensus.

• Ability to make effective oral presentations and prepare concise written reports to a variety of audiences.

• Ability to mediate and resolve complex problems and issues.

• Ability to plan, organize, prioritize, work independently and meet deadlines.

• Ability to provide leadership and influence others.

• Ability to supervise, coach, mentor, train, and evaluate work results.

• Ability to work effectively with individuals at all levels of the organization.

• Knowledge of computer systems and software used in functional area.

• Knowledge of medical terminology and related levels of care and treatment.

• 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 evaluation.

Physical Requirements and Working Conditions

The Physical Requirements and Working Conditions in which the job is typically performed are available from the Occupational Health Department. Reasonable accommodations will be made to enable individuals with disabilities to perform the essential functions of the job.

Equal Opportunity Employer

L ucile Packard Children's Hospital Stanford strongly values diversity and is committed to equal opportunity and non-discrimination in all of its policies and practices, including the area of employment. Accordingly, LPCH does not discriminate against any person on the basis of race, color, sex, sexual orientation or gender identity, religion, age, national or ethnic origin, political beliefs, marital status, medical condition, genetic information, veteran status, or disability, or the perception of any of the above. People of all genders, members of all racial and ethnic groups, people with disabilities, and veterans are encouraged to apply. Qualified applicants with criminal convictions will be considered after an individualized assessment of the conviction and the job requirements, and where applicable, in compliance with the San Francisco Fair Chance Ordinance.