Summary:

In a High Reliability Organization, the Program Manager Regulatory and Accreditation, provides support to leadership under the direction of the Director for Ambulatory Quality Management.

Manages system-wide processes for evaluating, monitoring, and improving compliance with internal and external requirements. Uses HRO Principles, Universal Skills, and Reliability Science to facilitate the system's standardized processes to prepare for, participate in, and follow up on regulatory, accreditation, and certification surveys and activities. Serves as a liaison to leadership in quality and clinical risk management to implement change. Provides guidance on how to facilitate the corrective action plans developed by leaders from the areas that were cited. Provides coaching of members of the leadership team on regulatory preparedness. Supports the policy, procedure, and document governance that guides safe, evidence-based practice of patient care. Works on performance improvement projects as directed by the Director Ambulatory Quality Management

Knowledgeable on accreditation agencies such as the CMS. Supports policy implementation for processes and programs facilitating regulatory and accreditation compliance with federal and state laws and regulations.

Responsibilities:

• Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders.
• Must communicate effectively to different audiences.
• Must be proficient in computer skills using EXCEL, PowerPoint, MSOffice, and Flowchart tools.
• Knowledgeable on High Reliability Principles, HRO Universal Skills, HRO Reliability Science preferred.
• Must have knowledge of PDSA methodology.

Source: NAHQ Workforce Accelerator Competency Framework 2022: Eight Domains

• Quality Leadership and Integration- Advance the organization's commitment to healthcare quality through collaboration, learning opportunities, and communication. Lead the integration of quality into the fabric of the organization through a coordinated infrastructure to achieve organizational objectives. Domain Level: Advanced
• Performance and Process Improvement- Use performance and process improvement (PPI), project management, and change management methods to support operational and clinical quality initiatives, improve performance, and achieve organizational goals. Domain Level: Advanced
• Population Health and Care Transitions- Evaluate and improve healthcare processes and care transitions to advance the efficient, effective, and safe care of defined populations. Domain Level: Proficient
• Health Data and Analytics- Leverage the organization's analytic environment to help guide data-driven decision-making and inform quality improvement initiatives. Domain Level: Advanced
• Regulatory and Accreditation- Direct organization-wide processes for evaluating, monitoring, and improving compliance with internal and external requirements. Lead the organization's processes to prepare for, participate in, and follow up on regulatory, accreditation, and certification surveys and activities. Domain Level: Advanced
• Patient Safety- Cultivate a safe healthcare environment by promoting safe practices, nurturing a just culture, and improving processes that detect, mitigate, or prevent harm. Domain Level: Advanced
• Quality Review and Accountability- Direct activities that support compliance with organization-wide voluntary, mandatory, and contractual requirements for data acquisition, analysis, reporting, and improvement. Domain Level: Advanced
• Professional Engagement- Engage in the healthcare quality profession with a commitment to practicing ethically, enhancing one's competence, and advancing the field. Domain Level: Proficient

Job Requirements:

Education/Skills

• Bachelor's Degree of Science in Nursing, or other clinical degree specialties required
• Master's degree preferred

Experience

• Five years of healthcare experience required
• Three years of quality management experience required

Licenses, Registrations, or Certifications

• Certified Professional in Healthcare Quality (CPHQ) is required at or within 1 year of hire

In accordance with the CHRISTUS Health License, Certification and Registration Verification Policy, all Associates are required to obtain the required certifications for their respective positions within the designated time frame.

Work Schedule:

8AM - 5PM Monday-Friday

Work Type:

Full Time

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About CHRISTUS Health

CHRISTUS Health is an international faith-based, not-for-profit health care system based in Irving, Texas, with more than 60 hospitals in Texas, Louisiana, New Mexico, Chile, Colombia and Mexico. CHRISTUS Health is made up of 50,000 Associates providing compassionate and individualized care at more than 600 centers, including community hospitals, clinics, long-term care facilities and health ministries. Sponsored by the Sisters of Charity of the Incarnate Word of Houston, Sisters of Charity of the Incarnate Word of San Antonio and the Sisters of the Holy Family of Nazareth, our mission is to extend the healing ministry of Jesus Christ to every individual we serve.

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