Strategic Services Associate -Accreditation and Regulatory Affairs
Duke University Health System
Location: Durham, North Carolina
Internal Number: 165088
Duke University Hospital is consistently rated as one of the best in the United States and is known around the world for its outstanding care and groundbreaking research. Duke University Hospital has 957 inpatient beds and offers comprehensive diagnostic and therapeutic facilities, including a regional emergency/trauma center; a major surgery suite containing 51 operating rooms; an endo-surgery center; an Ambulatory Surgery Center with nine operating rooms and an extensive diagnostic and interventional radiology area. In fiscal year 2018, Duke University Hospital admitted 42,916 patients and had 1,085,740 outpatient visits in fiscal year 2017.
U.S News & World Report named Duke University Hospital #1 in North Carolina and #1 in the Raleigh-Durham area in 2018-19.
Duke University Hospital is ranked in the top 20 nationally for seven adult specialties, including cardiology and heart surgery, nephrology, ophthalmology, orthopedics, pulmonology, rheumatology, and urology.
In addition to its hospitals, Duke Health has an extensive, geographically dispersed network of outpatient facilities that include primary care offices, urgent care centers, multi-specialty clinics and outpatient surgery centers.
Duke Nursing Highlights:
Duke University Health System is designated as a MagnetÂ® organization
Nurses from each hospital are consistently recognized each year as North Carolinaâ€™s Great 100 Nurses.
Duke University Health System was awarded the American Board of Nursing Specialties Award for Nursing Certification Advocacy for being strong advocates of specialty nursing certification.
Duke University Health System has 6000 + registered nurses
Quality of Life: Living in the Triangle!
Duke Hospital (Duke North 1300 Ste.) Durham, North Carolina
8:00am-5:00pm, Monday-Friday (This position is onsite and will require some local travel between Duke sites)
Contributes to the achievement of the hospital's mission through the development and leadership of performance improvement activities in the operational and/or clinical arenas. Assures continual compliance with regulations and accreditation standards through monitoring activities and the design and implementation of strategies to enhance compliance for the safe and high-quality care of DUH patients and employees.
Duties and Responsibilities:
· Supports the organization's efforts to maintain compliance with regulatory and accreditation requirements/standards.
· Monitors compliance through formal and informal processes.
· Recognizes opportunities for improving compliance with regulatory and accreditation requirements/standards.
· Designs and implements strategies for enhancing compliance with regulatory and accreditation requirements/standards.
· Evaluate the effectiveness of improvement strategies through sustained monitoring of performance.
· Participates and assists in coordinating regulatory/accreditation surveys.
· Uses proactive data analytics to advise the organization of potential regulatory and accreditation risks.
· Advises clinical areas/departments on policy drafts and revisions for DUH.
· Plans activities aimed at implementing standards/regulations and/or improving the hospital's performance in operations or clinical quality.
· Analyzes data to identify areas of opportunity for performance improvement.
· Serve as a project manager for interdisciplinary teams.
· Establishes performance targets.
· Evaluate the effectiveness of improvement strategy through sustained monitoring of performance.
· Contributes to the establishment of performance improvement priorities for departments, functional units, and the organization as a whole.
· Drafts and implements corrective action plans along with departmental leadership
· Increase organizational understanding of accreditation and regulatory requirements/standards through the support of and participation in formal and informal professional development activities.
· Serve as an expert resource on regulatory and accreditation requirements/standards.
· Produce reports and presentations on areas of accreditation and regulatory compliance.
· Develops, maintains, and enhances knowledge through orientation, self-evaluation, and professional development.
· Responsibilities may include varying levels of strategic planning/human/fiscal resource management.
· Facilitate the review, response, and documentation of complaints received from external parties in partnership with departmental leadership.
· Facilitates the procurement of additional licensures, accreditation, and certifications on behalf of DUH with input from departmental leadership.
- Perform other related duties incidental to the work described herein.
Knowledge, Skills and Abilities
Ability to manage numerous diverse projects simultaneously
Accreditation and Regulatory Affairs with Joint Commission experience and knowledge strongly preferred
Medicaid services experience strongly preferred
Process improvement and methodology
Bachelors degree in a business or health-related field is required.
Minimum of 5 years work experience, including 3 years of experience with significant responsibility for performance/ process improvement. Experience leading work teams required. Experience can be supplemented with Master's degree with a Masters being equivalent to two years of experience.
Duke is an Affirmative Action/Equal Opportunity Employer committed to providing employment opportunity without regard to an individual's age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, sex, sexual orientation, or veteran status.
Duke aspires to create a community built on collaboration, innovation, creativity, and belonging. Our collective success depends on the robust exchange of ideas—an exchange that is best when the rich diversity of our perspectives, backgrounds, and experiences flourishes. To achieve this exchange, it is essential that all members of the community feel secure and welcome, that the contributions of all individuals are respected, and that all voices are heard. All members of our community have a responsibility to uphold these values.
Essential Physical Job Functions: Certain jobs at Duke University and Duke University Health System may include essential job functions that require specific physical and/or mental abilities. Additional information and provision for requests for reasonable accommodation will be provided by each hiringdepartment.
As a world-class academic and health care system, Duke Health strives to transform medicine and health locally and globally through innovative scientific research, rapid translation of breakthrough discoveries, educating future clinical and scientific leaders, advocating and practicing evidence-based medicine to improve community health, and leading efforts to eliminate health inequalities.