Assistant Director of Quality, Regulatory Affairs and Accreditation

LOCATION: STROGER HOSPITAL

DEPARTMENT: Quality and Patient Safety

SHIFT: 8:30AM-4:30PM

Job Summary
The Assistant Director of Quality, Regulatory Affairs and Accreditation will assist with the Director of Quality, Regulatory Affairs and Accreditation in the strategic management and planning for Joint Commission Accreditation and accreditation related activities for all clinical services throughout Cook County Health (CCH), including hospitals, clinics, behavioral health centers and ambulatory surgery centers. Works with the Director to sets guidelines to meet requirements for Joint Commission Accreditation leading to successful accreditation for all entities within the health system. Assists the Director with the development and maintenance of a comprehensive accreditation project plan that includes standards education, prioritized interventions and on-going monitoring for standards compliance as established by Joint Commission for all accreditation requirements. Assists the director with the development and management of a plan to assure compliance with Centers for Medicare and Medicaid Services (CMS) Conditions of Participation. Assists in Coordinating efforts to earn outstanding clinical performance and a positive customer experience as required for accreditation. Assists in coordinating efforts to assure regulatory compliance with standards established by our managed care partners.

General Administrative Responsibilities

Collective Bargaining
* Review applicable Collective Bargaining Agreements and consult with Labor Relations to generate management proposals
* Participate in collective bargaining negotiations, caucus discussions and working meetings

Discipline
* Document, recommend and effectuate discipline at all levels
* Work closely with labor relations and/or labor counsel to effectuate and enforce applicable Collective Bargaining Agreements
* Initiate, authorize and complete disciplinary action pursuant to CCH system rules, policies, procedures and provision of applicable collective bargaining agreements

Supervision
* Direct and effectuate CCH management policies and practices
* Access and proficiently navigate CCH records system to obtain and review information necessary to execute provisions of applicable collective bargaining agreements

Management
* Contribute to the management of CCH staff and CCH' systemic development and success
* Discuss and develop CCH system policy and procedure
* Consistently use independent judgment to identify operational staffing issues and needs and perform the following functions as necessary; hire, transfer, suspend, layoff, recall, promote, discharge, assign, direct or discipline employees pursuant to applicable Collective Bargaining Agreements
* Work with Labor Relations to discern past practice when necessary

Typical Duties
* Assists the Director with development of and leadership support for a regulatory survey readiness program in support of the organization's mission, values and business objectives.
* Assists the director with on-going monitoring and reporting of compliance activities to senior management.
* Works with CCH senior management and clinical staff to support accreditation/certification processes and standards adherence.
* Conducts training and coaching to support understanding of accreditation, certification and/or other regulatory standards and requirements.
* Assists the director with development and maintenance of plans to assure compliance with regulatory requirements of managed care plans.
* Assists CCH leadership and other management as appropriate in ensuring regulatory and compliance readiness.
* Conducts audit activities to ensure compliance with accreditation standards and assists with the development and maintenance of compliance database.
* Assists the director with maintaining the accreditation/certification and audit document library.
* Oversees the currency and archiving of the institutional policy library in electronic and/or paper formats.
* Provides oversight and collaborates with responsible parties, committees, and departments to develop, implement and maintain a coordinated approach to policy and procedure development, maintenance and retention throughout the organization.
* Assesses and monitors all CCH policies and procedures for consistency and compliance with regulatory, accreditation, licensure, and professional standards supporting inspection readiness in support of the organization's mission, values and business objectives.
* Serves as a policy and procedure resource for staff throughout CCH.
* Assists managers to identify and facilitate changes to ensure accuracy and consistency of policy and procedures and support compliance.
* Serves as workflow content expert for on-line policy posting and management. Works with software vendor and CCH Hospital Information Systems' staff to ensure optimum functionality, continuous training for and development of the policy and procedure portal.
* Performs other duties as assigned.

Minimum Qualifications
* Bachelor's degree from an accredited college or university
* Three (3) years of experience in a management or leadership role within a large hospital or healthcare system
* Three (3) years of experience with accreditation and regulatory survey processes, including development and follow-up of corrective action plans
* Two (2) years of experience with development, implementation and communication of and training related to organizational policies and procedures
* Proficient in Microsoft Office (Outlook, Excel, Word, PowerPoint)

Preferred Qualifications
* Masters' degree from an accredited college or university
* Two (2) or more years of experience working with web-based/on-line policy and procedure management software
* Two (2) or more years of experience working in a unionized environment
* One (1) or more years of experience with project management

Knowledge, Skills, Abilities and Other Characteristics
* Excellent verbal and written communication skills necessary to communicate with all levels of staff and present information to different audiences
* Excellent organizational skills
* Strong problem-solving skills used to anticipate and identify issues as well as to develop and
implement appropriate solutions related to complex administrative processes
* Strong customer service skills
* Demonstrated ability to lead and/or support a team
* Detail-oriented and task-oriented
* Ability to function independently and meet deadlines
* Working knowledge of common healthcare-associated regulatory standards (e.g. Joint Commission, OSHA, etc.) and CMS Conditions of Participation
* Must be able to work flexible hours
* Must be able to travel throughout Cook County

Physical and Environmental Demands
This position is functioning within a healthcare environment. The incumbent is responsible for adherence to all hospital and department specific safety requirements. This includes but is not limited to the following policies and procedures: complying with Personal Protective Equipment requirements, hand washing and sanitizing practices, complying with department specific engineering and work practice controls and any other work area safety precautions as specified by hospital wide policy and departmental procedures.

The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of the personnel so classified.

For purposes of the American with Disabilities Act, "Typical Duties" are essential job functions.

VETERAN PREFERENCE

PLEASE READ

When applying for employment with Cook County Health, preference is given to honorably discharged Veterans who have served in the Armed Forces of the United States for not less than 6 months of continuous service

To take advantage of this preference a Veteran must:

• Meet the minimum qualifications for the position.
• Identify self as a Veteran on the employment application by answering yes to the question by answering yes to the question, "Are you a Military Veteran?"
• Attach a copy of their DD 214, DD 215 or NGB 22 (Notice of Separation at time of application filing. Please note: If you have multiple DD214s, 215s, or NGB 22S, Please submit the one with the latest date. Coast Guard must submit a certified copy of the military separation from either the Department of Transportation (Before 9/11) or the Department of Homeland Security (After 9/11). Discharge papers must list and Honorable Discharge Status. Discharge papers not listing an Honorable Discharge Status are not acceptable

OR

• A copy of a valid State ID Card or Driver's License which identifies the holder of the ID as a Veteran, may also be attached to the application at time of filing.

If items are not attached, you will not be eligible for Veteran Preference

VETERANS MUST PROVIDE ORIGINAL APPLICABLE DISCHARGE PAPERS OR APPLICABLE STATE ID CARD OR DRIVER'S LICENSE AT TIME OF INTERVIEW.

Benefits Package

• Medical, Dental, and Vision Coverage
• Basic Term Life Insurance
• Pension Plan
• Deferred Compensation Program
• Paid Holidays, Vacation, and Sick Time
• You may also qualify for the Public Service Loan Forgiveness Program (PSLF)

For further information on our excellent benefits package, please click on the following link: http://www.cookcountyrisk.com/

MUST MEET ALL REQUIRED QUALIFICATIONS AT TIME OF APPLICATION FILING.

*Degrees awarded outside the United States with the exception of those awarded in one of the United States' territories and Canada must be credentialed by an approved U.S. credential evaluation service belonging to the National Association of Credential Evaluation Services (NACES) or the Association of International Credential Evaluators (AICE). Original credentialing documents must be presented at time of interview.

*Please note all offers of Employment are contingent upon the following conditions: satisfactory professional & employment references, healthcare and criminal background checks, appropriate licensure/certifications and the successful completion of a physical and pre-employment drug screen.

*CCH is strictly prohibited from conditioning, basing or knowingly prejudicing or affecting any term or aspect of County employment or hiring upon or because of any political reason or factor.

COOK COUNTY HEALTH IS AN EQUAL OPPORTUNITY EMPLOYER