Supervisor-Accreditation and Licensure

General Summary

Provides direction and leadership by coordinating activities designed to achieve and maintain compliance with the PA Department of Health, entity/area accreditation organizations, CMS Conditions of Participation, and the Department of Human Services regulations for several assigned WellSpan entity/ies and/or area(s). Performs a variety of audits, analysis of the data as well as ensures compliance with regulatory audits. Acts as coordinator for on-site surveys and works in collaboration with others to facilitate system process and outcome improvements. Working with clinical teams and entity operational staff, determines root cause for identified defects and deficiencies and prepares standard work and policy recommendations as appropriate. Liaises with Medical Staff Services team members who work with the same WellSpan entity/ies and/or area(s) in the areas of credentialing, clinical privileges, and medical staff governance. For staff who support specific WellSpan licensed entities, serves as the on-site representative for Medical Staff Services related issues for that entity as required. Spreads information through communication forums such as WellSpan's Chief Quality Officer Team, Accreditation and Licensure Team (ALT), and Medical Staff Services (MSS) Team.

Duties and Responsibilities

Remote Work Capable

Essential Functions:

• Provides direct supervision of staff, oversees change management, completes performance evaluations, hires and ensures appropriate training of staff, ensures an effective daily engagement/tiered huddle process, and develops and monitors Key Performance Indicators to ensure success of department and system objectives.
• Accountable for the accreditation, certification, and/or licensure of multiple licensed entities and/or system departments, ensuring all applicable standards and requirements are met.
• Participates in the WSH Accreditation/Risk Management on-call rotation with appropriate supervision by a team member with Certification in Professional in Healthcare Risk Management (CPHRM). Once certified, assumes independent responsibilities in the WSH Accreditation/Risk Management on-call rotation.
• Works closely with leadership and appropriate staff to coordinate survey activities, including appropriate planning, monitoring systems, clarifications, and challenges.
• Keeps abreast of regulatory agency, accreditation organization, and program certification requirements for areas or responsibility and ensures stakeholders are informed and educated on those requirements through educational sessions, Continuous Survey Readiness meetings, and related activities.
• Initiates proactive risk assessments, gap analyses regarding standard and other regulatory compliance, and internal audits as well as analyzing the resulting data and developing appropriate actions, reporting results to the appropriate oversight committee(s), and plans intervention activities for improvement, as appropriate.
• Compiles data for and prepares regularly scheduled or special reports, analyses, and statements.
• Develops and oversees the implementation of corrective action plans to address survey findings.
• Serves as a liaison and subject matter expert to the Medical Staff Services team and if supports a specific WellSpan licensed entity, serves as the on-site representative for Medical Staff Services related issues for that entity.
• Is an active participant in the entity/program area(s)’ committees and councils, such as Quality Management Committee, Environmental Safety Committee, Emergency Management Committee, and Environment of Care Rounds, or equivalent for areas of responsibility.
• Develops, establishes, and implements goals, objectives, and policies and procedures for department and entity/area operations, which guide and support the provision of services.
• Continuously assesses and improves the department, entity/area’s performance. Maintains appropriate quality control/assessment programs (if applicable). Stewards principles of ISO 9001 Quality Management and risk based thinking.

Common Expectations:

• Demonstrates a commitment to patient, visitor, and staff by: complying with all applicable safety regulations; learning the impact of medical errors and methodology that will lead to reduction of errors; reporting actual and potential errors, as well as hazardous conditions; identifying opportunities to standardize processes and "error proof" systems that will lead to increased safety; and participating in safety education programs and root cause
• Maintains established policies and procedures, objectives, quality assessment, safety, environmental and infection control standards.
• Enhances professional growth and development through participation in educational programs, current literature, in-service meetings, and workshops.
• Provides outstanding service to all customers; fosters teamwork; and practices fiscal responsibility through improvement and innovation.
• Builds and maintains collaborative, supportive, and mutually accountable relationships with team members.

Travel Requirements:

• Estimated Amount: - Travel to all entities in WellSpan service area for survey activity and support activities.