The regulatory function is vital in making safe and effective healthcare products available worldwide. Individuals who ensure regulatory compliance and prepare submissions, as well as those whose main job function is clinical affairs or quality assurance are all considered regulatory professionals.
One of our most valuable contributions to the profession is the Regulatory Code of Ethics. The Code of Ethics provides regulatory professionals with core values that hold them to the highest standards of professional conduct.
Like all professions, regulatory is based on a shared set of competencies. The Regulatory Competency Framework describes the essential elements of what is required of regulatory professionals at four major career and professional levels.
Join the brightest minds in regulatory at the annual Regulatory Convergence. See the global regulatory community in action. Intensive workshops. Topical sessions. Meet ups with regulators. This is where it all comes together.
Under the supervision of the Vice President, Professional and Quality Services, the Director of Quality and Accreditation is responsible for the integration of all components involved in organizational and medical staff quality of care, safety, measurement, informatics, and performance improvement. The Director provides leadership and direction for the medical center’s programs for healthcare informatics, quality & outcomes management, decision support analysis, infection prevention, risk management and patient safety. The Director will also oversee Joint Commission and state/federal accreditations, ensuring compliance with all requirements and standards, and will be instrumental in promoting quality of life for patients, personnel and the community served.
Maintains a working knowledge of applicable federal, state, and local laws and regulations, the organizational integrity program, code of ethics, as well as other policies and procedures.
Supports the organization in achieving strategic and operational goals for quality management and reporting, patient safety, performance improvement, and information management.
Serves as the in-house expert on JCAHO standards, and has overall responsibility for accreditation processes and regulatory programs.
Assesses compliance to JCAHO standards with recommendations for change. Annually evaluates effectiveness of monitoring system.
Serves as the liaison to parent organization for all regulatory and accreditation matters. Collaborates with parent company accreditation and regulatory services in preparing/maintaining compliance for medical center respective to all regulatory bodies.
Functions as liaison to support multidisciplinary process improvement teams. Provides summarized reports regarding performance improvement events and activities to the board, quality committee, hospital administration, medical staff and appropriate committees on a regular basis.
Facilitates and promotes best practice research utilization in development and implementation of standards, policies, and procedures to support quality and safety of patient care services.
Ensures compliance with all regulatory and accrediting bodies for quality outcomes associated with tracking/reporting, performance improvement, patient safety, risk management, infection control, clinical documentation, and medical staff credentialing and reappointment.
Develops and implements the organization’s and medical staff’s quality improvement plan in accordance with the mission and strategic goals of the organization, federal and state laws and regulations, and accreditation standards.
Directs the development and implementation of systems, policies, and procedures for the identification, collection, and analysis of performance measurement data. Develops and oversees a contemporary, efficient system of quality and safety measurement that delivers timely and effective reporting to regulatory agencies and to other internal and external audiences.
Directs programs, systems and processes for measurement, evaluation, and performance improvement by ensuring that all clinical departments receive relevant information regarding their outcomes of care, clinical processes and pertinent benchmarks.
Provides leadership and strategic direction for healthcare informatics programs, projects, and services; evaluates periodic structured assessments and recommendations on the future direction for healthcare informatics.
Directly supports the quality committee of the board of trustees, the performance improvement & patient safety committee, and the medical staff quality committee. Actively participates in the executive safety committee, nursing leadership committee and other ad hoc committees as requested.
Serves as a consultant and provides education to facility and medical staff leadership, and the board of trustees, regarding all aspects of quality and performance improvement.
Actively participates in global initiatives to improve quality, safety, service, and clinical informatics.
Assists the medical staff leadership with quality-related issues.
Identifies needs and implements quality improvement education of organizational staff and physicians, leading to practice improvement, clinical outcome improvement and medical staff satisfaction.
Orients physicians, staff and peers to the research process and/or quality improvement.
Coordinates and integrates processes across medical center to analyze and trend quality data.
Develops processes for selecting and coordinating performance improvement teams and projects; incorporates CQI philosophy, methods, and tools into the process; integrates care management programs into the overall quality improvement program.
Provides leadership to the organization and medical staff in preparation for JCAHO accreditation and compliance with other regulatory bodies.
Maintains personal professional growth and development, remaining current with the latest trends, techniques, advances, and technologies in the fields relating to quality and service. Participates in professional organizations dedicated to the promotion of quality services. Represents medical center by participation in community, civic, and professional organizations.
Responsible for creating an environment of organizational learning about patient safety and medical/health care error reduction; supports sharing of knowledge and fosters behavioral changes to improve patient safety.
Actively participates in improving patient safety and reducing risk to patients. Complies with safety and infection control policy & procedures.
Maintains confidentiality of information pertaining to clients, physicians, employees, and medical center business.
Demonstrates general working knowledge of computers and department-specific software (i.e., Healthstream, Internet, etc.)
Performs other duties and responsibilities as assigned.
Master's degree in Healthcare Administration, Business, Nursing, or related field required.
Requires a minimum of five to seven years of related clinical/patient care experience with a minimum of three to five years of previous management experience in quality management, project management, patient safety, performance improvement and healthcare informatics, and in JCAHO survey preparation.
Demonstrated leadership skills in program development and implementation.
Must demonstrate a thorough understanding of quality Improvement/process Improvement concepts with knowledge of clinical and administrative issues currently affecting the health care industry.
Thorough knowledge of data management with demonstrated success in information management and reporting.
Strong quantitative and analytical skills with the ability to work under deadlines and handle multiple, detailed tasks.
Requires ability to handle difficult situations given diverse perceptions and strong personalities in often challenging settings.
Excellent written/oral communication skills. Demonstrates ability to communicate effectively with staff, physicians, and other allied health professionals.
Must have a general working knowledge of computers and department-specific software (i.e., Healthstream, internet, etc.)
Must be comfortable operating in a collaborative, shared leadership environment.
Must possess a personal presence characterized by a sense of honesty, integrity, and caring, with the ability to inspire and motivate others to promote the philosophy, mission, vision, goals, and values of the medical center and parent organization.
Additional Salary Information: Very competitive, commensurate with experience and salary history.
All submissions and inquiries held in strict confidence.
Internal Number: 1918
About MercyOne Siouxland Medical Center
Acute care medical center serving 33 counties in three states.