Principal Duties:

1. Provide oversight and direction to endure that UM Capital meets regulatory requirement mandated by Joint Commission accreditation, CMS Conditions of Participation, OSHA, and state and federal regulations.

• Assume management responsibility over all accreditation and regulatory functions ensuring safe care and compliance.
• Serve as an expert resource on accreditation and regulatory issues for UM Capital staff, physicians and leadership.
• Maintain current awareness of state, federal and national regulations required to maintain accreditation and/or certification for all areas of UM Capital.
• Ensure timely completion and oversee the completion of ongoing self-assessments for standard compliance for the annual Joint Commission Periodic Performance Review and Measures of Success.
• Prepare reports and evaluate progress regarding status of compliance for improvements and deficiencies identified by regulatory deficiencies.
• Submit timely reports to the regulatory entities related to action plans as well as follow up for areas in need of improvement.
• Serve as the system representative for external interaction with accreditation and regulatory entities

2. Provide leadership in the development and implementation of strategies regarding continuous regulatory readiness, education of the regulatory standards and revise education as standards change.

• Coordinate and facilitate the Continuous Survey Readiness Committee and ensure Chapter Captains are current on all requirements.
• Identify areas in which UM Capital does not meet the intent of the standards. Coordinate work groups and/or performance improvement activity to bring the standard in line with the regulations.
• Collaborate with UM Capital physicians, coordinators, leaders and executives to address areas of opportunity, identify strategies to improve performance, implement and evaluate corrective actions.
• Plan and oversee mock surveys and associated action plans.
• Develop strategies to enhance compliance and work with leaders and executives to assure execution.

3. Responsible for regulatory complaint surveys and follow up.

4. Assure policies and procedures are updated as required.

5. Supervise Accreditation personnel

6. Perform other duties as assigned by the Vice President for Quality and Safety