Overview

UnityPoint-St Luke's

Full-Time Days

Monday-Friday

The Accreditation and ISO Program Manager provides oversight to ensure a continuous state of readiness with all regulatory and accrediting agencies, including DNV, CMS, and state health departments. This role leads and contributes to efforts to drive high reliability and achieve compliance with accreditation standards and regulatory requirements. The Accreditation and ISO Program Manager collaborates across departments to oversee audits and surveys, ensure timely implementation of corrective actions and performance improvement strategies.

Responsibilities

Survey Coordination & Readiness

Serve as a primary point of contact for accrediting and regulatory bodies (e.g., DNV, IDPH, IDIAL, WDHS, CMS).
• Lead regulatory surveys, compiles action plans from the responsible
parties and submits plans by due date.
• Support internal investigations that may require self reports to
regulatory agencies.
• Tracks and communicates progress in meeting the action plans.
• Monitors changes in regulatory standards and provides education to
staff and leadership regarding standards or interpretive guidelines.
• Acts as a resource to committees/workgroups regarding required
regulations.
• Performs audits as appropriate to assure compliance with standards or
changes in standards.
• Maintains a master list of ISO audits done annually.
• Tracks action plans associated with ISO audits.
• Assures results of all ISO audits are presented/discussed with the
Quality Management Oversight Committee.
• Lead the development and implementation of a robust continuous
survey readiness program.
• Coordinate all accreditation surveys and facilitate mock surveys,
tracers, and documentation review
• Serve as a subject matter expert to hospital leadership, departments,
and committees on regulatory standards.
• Maintains market level accreditation applications and leads self
reporting processes.
• Travel, with no notice, to other UPH hospitals to support surveys and
survey readiness

Operational Improvement

Partners with internal, external, and community stakeholders to assist
with strategy development and improvement.
• Coordinates plans that include a regional vision to the system
strategy.
• Works to continually lead improvement processes and incorporate the
latest evidence-based guidelines and standards into practice, providing
innovative solutions for process improvement and operational
improvement.
• Analyzes data, communicating with key leaders and clinicians to
improve results.
• Assists with root cause analyses process and shares as needed, driving
improvement.

Program and Project Leadership

Leads market level project teams to define, improve, and evaluate
processes. Uses principles of performance improvement to standardize
and hardwire.
• Works closely with quality improvement, patient care services, nursing
operations and many other stakeholders to utilize data to drive change
through implementation of plans.
• Leads market level initiatives and improvements between departments
and differing levels of care to obtain/maintain optimal processes.
• Serves as a point of contact for teams when multiple areas are
assigned to the same project to ensure team actions remain in sync.
• Develops and delivers content, policies, procedures, and education.
• Performs analysis of existing tools to identify further optimization /
opportunities.
• Exhibits collegial communication skills that enhance outcomes and
goal attainment, leads in a manner that unifies and enhances success.

Qualifications

• Education: Bachelor's degree in healthcare related field or leadership required.
• Experience: Minimum of 5 years' experience in healthcare setting and previous experience with quality improvement processes and analytical skills required.
• License/Certifications: Certified Healthcare Operations Professional-Basic or Advanced- DNV Healthcare, Inc. within 1 year required
• Knowledge/Skills/Abilities: Consistently utilizes exceptional written and verbal communication skills. Quickly establishes effective working relationships with multiple stakeholders. Accountable for delivery of outcomes according to plans and timelines. Manages multiple priorities and deadlines to meet goals of the region. Utilizes exceptional planning and organizational skills. Proficient in Microsoft tools, spreadsheets, outlook, and web. Strong quantitative and qualitative data analysis skills to find creative solutions to difficult and complex problems. Strives for improved outcomes/measures, develop positive working relationships with the multidisciplinary network of stakeholders, and maintain a proactive approach to quality improvement. Travel Required.