To assist in the development, coordination and implementation of activities to assure compliance with accreditation and regulatory requirements
Provide in-depth understanding of current practices in UMHS
Support clinical compliance with the TJC, State and Federal regulations
Implement and assist in the evaluation of ongoing compliance with accrediting and regulatory standards
Participate in accreditation and regulatory survey visits
Assist in preparing status reports, proposals and presentations as assigned
Provide direction and oversight for regulatory and accreditation compliance including TJC, State and Federal agencies. Coordinate designated efforts to assure compliance with accreditation and regulatory requirements including Developing systems to ensure continual organizational readiness; Gathering, synthesizing, and analyzing data from departments; Providing consultation to departments around compliance initiatives; Monitoring the progress of corrective action plans/improvement projects. Remain current with accreditation and regulatory standards. Audit and provide feedback on regulatory compliance. Function as a resource and educator to support the management team and staff of the organization on accreditation plans to assure compliance. Develop and implement annual Continuous Readiness Plan to achieve compliance with accreditation and regulatory standards. Participate in accreditation and regulatory visits. Monitor adherence to institutional programs and materials related to accreditation and regulatory requirements. Coordinate and communicate educational offerings related to accreditation and regulatory requirements across the organization. Assist in preparing status reports, proposals and presentations as assigned. Maintain collaborative relationships between impacted departments, units, hospitals/healthcare centers and appropriate regulatory agencies. Other duties as applicable.
Bachelor’s degree in Nursing, other health care field, or quality is required.
Additional educational training in Joint Commission accreditation standards is required.
Demonstrated knowledge of process improvement and outcome measurement is essential.
Knowledge of quality improvement tools.
Excellent interpersonal skills, as demonstrated by the ability to work effectively with individuals and/or teams, across disciplines, is essential.
Demonstrated skills and competence in accreditation and regulatory compliance.
Proven organizational skills.
Excellent communication skills, as demonstrated in oral, written and presentation forms is necessary.
Masters degree in a health care field or quality preferred
Current State of Michigan Board of Nursing licensure, if applicable
Ability to use web publishing tools is desired
Certified as a Join Commission Professional, CJCP
Michigan Medicine conducts background screening and pre-employment drug testing on job candidates upon acceptance of a contingent job offer and may use a third party administrator to conduct background screenings. Background screenings are performed in compliance with the Fair Credit Report Act. Pre-employment drug testing applies to all selected candidates, including new or additional faculty and staff appointments, as well as transfers from other U-M campuses.
Michigan Medicine improves the health of patients, populations and communities through excellence in education, patient care, community service, research and technology development, and through leadership activities in Michigan, nationally and internationally. Our mission is guided by our Strategic Principles and has three critical components; patient care, education and research that together enhance our contribution to society.
Job openings are posted for a minimum of seven calendar days. The review and selection process may begin as early as the eighth day after posting. This opening may be removed from posting boards and filled anytime after the minimum posting period has ended.
The University of Michigan is an equal opportunity/affirmative action employer.
Internal Number: 191460
About University of Michigan - Ann Arbor
A great university is made so by its faculty and staff, and Michigan is recognized as one of the best universities to work for in the country. The Michigan culture is known for engaging faculty and staff in all facets of the university to create a workplace that is vibrant and stimulating.For two consecutive years, the Chronicle of Higher Education has placed U-M in its "Great Colleges to Work For" survey. In particular, the university earns high marks for strong relations between faculty and administrators, a collaborative system of governance, strong pay and benefits, and a healthy work/life balance.