System Vice President, Regulatory & Accreditation

System Vice President, Regulatory & Accreditation

Job Overview:

The Vice President, Regulatory & Accreditation is a system level leader accountable for strategic oversight and support for RWJBH clinical locations accreditation, licensure and regulatory preparation needs. This role will provide primary operational support to our hospitals, matrixing with embedded local quality resources team members for regulatory, accreditation and licensure needs. The System VP, Regulatory & Accreditation will matrix with service line and ambulatory clinical setting leadership to support operational needs as requested. This role is accountable to mature RWJBH s proactive preparation for regulatory, accreditation and certification activity, support ongoing regulatory activity, and create a cohesive regional approach to drive performance success at local facility regulatory, accreditation and certification needs.

Reports to:

• The System Vice President, Regulatory & Accreditation reports directly to the Senior Vice President of Patient Safety & Quality at RWJBarnabas Health.

Qualifications:

• 7-10+ years experience leading regulatory and accreditation activity impacting clinical locations; hospital health system experience preferred
• Bachelor s degree in business or health related area required
  • Master s degree in business or clinical area preferred
• 5 years experience supervising teams as manager or director; previous multi-hospital system leadership experience preferred.
• Clinical experience preferred

Essential Functions:

• Partner with System and local quality leaders to advance licensed health care organization survey and accreditation readiness
• Support local clinical settings during accreditation and survey activity, including guiding best practices for action plans in response to survey findings. Ensures timely response to any regulatory or accrediting body required action plans or responses
• Develops relationship with DOH, Joint Commission and DNV contacts. Acts as a liaison when clarification is requested by these entities of local hospital regulatory teams
• Establish and coordinate system-wide mock audit processes at clinical locations in preparation for licensure and/or accreditation surveys
• Mature RWJBH use of electronic capture of regulatory and accreditation activity, including mock audit, tracers and citation/deficiency findings
• Share lessons learned in survey and accreditation preparation from accrediting and licensing body visits
• Subject matter expert in the current CMS, NJ DOH, Joint Commission and DNV regulations. Serves as the system internal expert. Constant surveillance for new and/or proposed changes in regulations with system wide communication
• Be a role model, mentor and leader for excellence in regulatory and accreditation activity, incorporating a standard for zero preventable harm while maintaining and integrating High Reliability Organization principles
• Partner with legal and corporate affairs for regulatory and accreditation interpretation.
• Develops a strong regulatory system team approach, including regional coverage and onsite support for mock audits and regulatory and/or accrediting activity
• Leads System Clinical/Care of the Patient Policy & Procedure Governance Committee. Accountable for developing and maturing processes to guide clinical locations in best practices for timely policy and procedure development and/or revisions, including facilitating engagement of key subject matter expert stakeholders, approval of clinical executives and supporting a quality communication and education plan is in place
• Development of data visualizations of system and local performance in regulatory and accreditation trends. Audiences will include local and system executives and the Quality Committee of the System Board of Directors
• Matrixes with RWJBH corporate leaders in pharmacy, laboratory and radiology as required to support clinical regulatory and accrediting needs
• Facilitates internal regulatory and accreditation communications updates as needed in partnership with RWJBarnabas Health marketing & communications

Other Duties:

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.

Benefits and Perks:

At RWJBarnabas Health, our market-competitive Total Rewards package provides comprehensive benefits and resources to support our employees physical, emotional, social, and financial health.

• Paid Time Off (PTO)
• Medical and Prescription Drug Insurance
• Dental and Vision Insurance
• Retirement Plans
• Short & Long Term Disability
• Life & Accidental Death Insurance
• Tuition Reimbursement
• Health Care/Dependent Care Flexible Spending Accounts
• Wellness Programs
• Voluntary Benefits (e.g., Pet Insurance)
• Discounts Through our Partners such as NJ Devils, NJ PAC, Verizon, and more!

Choosing RWJBarnabas Health!

RWJBarnabas Health is the premier health care destination providing patient-centered, high-quality academic medicine in a compassionate and equitable manner, while delivering a best-in-class work experience to every member of the team. We honor and appreciate the privilege of creating and sustaining healthier communities, one person and one community at a time. As the leading academic health system in New Jersey, we advance innovative strategies in high-quality patient care, education, and research to address both the clinical and social determinants of health.

RWJBarnabas Health aims to truly make a unique impact in local communities throughout New Jersey. From vastly improving the health of local residents to creating educational and career opportunities, this combination greatly benefits the state. We understand the growing and evolving needs of residents in New Jersey whether that be enhancing the coordination for treating complex health conditions or improving community health through local programs and education.