Director, Quality and Regulatory Programs

JOB SUMMARY

Provides organizational leadership and content expertise for Quality and Regulatory affairs to all Shore Regional Health (SRH) entities. Collaborates with and participates in UMMS system-wide Quality and Regulatory initiatives to ensure SRH alignment and performance in accordance with UMMS standards and expectations.

Regulatory Affairs

Establishes and leads the organization in maintaining continuous regulatory and survey readiness culture for all entities and facilities operated by SRH. Primary duties include educating, monitoring, and identifying areas of opportunity to assure standards for accrediting agencies such as the Joint Commission, Department of Health & Mental Hygiene, and Centers for Medicare & Medicaid Services, Commission for the Accreditation of Rehabilitation Services, as well as other regulatory institutions as necessary. Leads and works collaboratively with internal and external partners to achieve positive outcomes.

Quality

Establishes and leads the organization in maintaining compliance with all required and applicable quality reporting to internal and external stakeholders. Ensures the accuracy and appropriateness of all data collected and reported. Identifies data driven opportunities for clinical improvement and takes action to address, including leading quality improvement teams and partnering with applicable department leaders as stakeholders and process owners. Oversees the organizational policy management process. Serves as a subject matter expert regarding the HSCRC quality programs.

ESSENTIAL JOB FUNCTIONS

1. 1. Develops, implements, and manages system-wide programs to promote continuous compliance with accreditation standards, Medicare/Medicaid Conditions of Participation/Coverage, and related requirements of the State of Maryland.
   2. Manages official communication with accrediting and Regulatory bodies assuring timely completion of reports, corrective action plans, and responses to inquiries. 
   3. Oversees and participates in the survey process including identifying individuals to be involved in survey activities, communicating survey timelines, and providing coaching/issue clarification as needed.
   4. Develops a palpable state of continual readiness in daily operations, as well as emergent situations.
   5. Facilitates tracer and mock survey activities throughout UM SRH and develops action plans in response to findings in collaboration with department leaders.
   6. Reviews literature, communication, and scouting reports regarding updates in regulatory standards and survey processes. Facilitates change to insure implementation of learnings.
   7. Acts as a consultant and advisor to organizational leadership, including physician leaders, in developing and sustaining an organizational culture which consistently produces high reliability outcomes.
   8. Serves as a change agent for the organization, assists organizational leaders and teams to facilitate major change and sustainable organizational improvement.
   9. Acts as a consultant and advisor to departmental leadership to build consensus and support for quality improvement initiatives at the organizational and departmental level. Develops compelling value propositions and business cases for proposed initiatives.
   10. Primary subject matter expert for regulatory Quality and performance improvement standards (i.e. The Joint Commission PI and CMS QAPI), leads efforts to achieve and maintain compliance.
   11. Educates all levels of the organization regarding regulatory and quality standards and techniques.
   12. Evaluates and revises the Quality Improvement Program to reflect current developments, national trends, and best practices.
   13. Provides oversight to quality improvement committees and accreditation readiness teams.  Participates in other committees as identified by leadership.
2. 1. Partners with the Patient Safety team in facilitation and support of root cause analysis and FMEA.
   2. Partners with the UM SRH Transformation Office in support of high reliability organizing and performance improvement.
3. 1. Oversees the UM SRH policy management program, partnering with process owners in ensuring all UM SRH organizational policies are up to date and relevant.
   2. Leads Quality and Regulatory team members on a daily basis, participates in the development of departmental goals, fosters a departmental culture of learning, achievement, and growth.
   3. Develops and manages operational budgets to ensure optimal financial performance of respective departments.