Employment Type:Full timeShift:Day Shift

Description:Provides leadership and strategic direction to Trinity Health member organizations (RHM's), and other operating entities in the design and implementation of systems, structures and processes that assure compliance with external accreditation and regulatory standards. Accountable for clinical and administrative system-wide performance improvement activities for eleven functional areas (patient rights, assessment of patients, care of patients, education, continuum of care, improving organizational performance, leadership, environment of care, human resource, management of information, infection control; governance, management, medical staff and nursing) to ensure compliance with standards and coordination of key processes and improvement efforts.

Job Purpose-

1.             Knows, understands, incorporates, and demonstrates the Trinity Health mission, 

vision, and values in leadership behaviors, practices and decisions.

2.             Directs the development and implementation of system and processes to:

A.            Achieve and maintain full licensure and accreditation.  In doing so, provides coordination and oversight to Trinity Health multi-system mock and actual surveys, analysis of system-wide trends, and preparation of appropriate reports for Trinity Health leadership and governance.

B.            Continuously improve performance with clinical and administrative standards as demonstrated by full compliance with federal, state and local regulatory bodies, and other external agencies (i.e. JCAHO, HCFA, DNV).  System Office and local RHM's evaluate the state of readiness on compliance performance with accreditation standards and collaborate with clinical operational leaders to improve performance.

3.             Provides direction to clinical and administrative leadership groups to ensure understanding of current accreditation/ regulatory standards, performance and action plans to meet or exceed the standards.

4.             Establishes strong relationships with accreditation and regulatory agencies to ensure that Trinity Health and its operating entities are actively involved in and represented on issues related to regulatory compliance.

5.             Establishes and maintains effective relationships with member organizations, corporate office leadership, and subsidiaries in order to anticipate and support their needs related to accreditation/regulatory compliance issues and to ensure orchestration and coordination of efforts.

6.             Directs the design and delivery of educational programs for Trinity Health that enhances knowledge and performance related to accreditation and regulation.

7.             Leads the design and implementation of performance improvement initiatives and process improvement teams that address strategic regulatory and compliance priorities.

8.             Serves as an expert resource for the interpretation of regulatory standards and the intent of those standards.

9.             Provides leadership and direction to the Trinity Health Accreditation Liaison Network.

10.          Maintains a working knowledge of applicable Federal, State and local laws/regulations; the Trinity Health Integrity and Compliance Program and Code of Conduct; as well as other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical and professional behavior.

11.          Represents Trinity Health when requested in responding to draft standards and engaging in liaison activities with national regulatory and accreditation bodies. 

12.          Assures efficient and effective use of electronic tools to improve auditing and tracking functions in order to proactively improve results of regulatory and  accreditation visits.

13.          Manages and directs external resources as required to proactively or reactively respond to accreditation and regulatory standards in collaboration with RHM and ministry leadership.

MINIMUM QUALIFICATIONS

Master's degree in a health-related or business field.

A minimum of five (5) years of leadership experience within a healthcare delivery system with an in depth understanding of regulatory requirements and healthcare operations.

Demonstrated experience with performance improvement and continuous quality improvement methodologies.

Strong analytical skills.

Strong critical thinking and problem solving skills.

Ability to function effectively within a matrix leadership structure.

Strong interpersonal skills that support critical communication with external regulatory agencies, senior leadership and the individual member organizations teams.

8.Must possess a personal presence which is 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 Trinity Health.

9.Must be able to operate effectively in a collaborative, shared leadership environment.

Our Commitment to Diversity and Inclusion
 

Trinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and inclusion in all that we do. Our colleagues have different lived experiences, customs, abilities, and talents. Together, we become our best selves. A diverse and inclusive workforce provides the most accessible and equitable care for those we serve. Trinity Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by law.