Regulatory and Accreditation Program Manager

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POST DATE 9/16/2016
END DATE 1/5/2017

Beth Israel Deaconess Medical Center Boston, MA

Boston, MA
AJE Ref #
Job Classification
Full Time
Job Type
Company Ref #
Mid-Career (2 - 15 years)
Bachelors Degree


JOB SUMMARY: The Regulatory and Accreditation Program Manager reports to the Director, Regulatory Affairs. Manages the accreditation/regulatory program requirements related to Joint Commission, CMS and the MA Department of Public Health/Licensing Requirements . This position Is responsible for administrative and coordinating functions Pre and Post accreditation surveys (Application, communicates with service line leads regarding action plan and next step in preparation for or following inspection surveys, coordinates response assessment dashboards, and MOS Design, etc.) as well as other large scale quality and safety survey coordination and compliance.
Acts as project resource and partner with the project managers, data abstractors, data analyst and other hospital staff to create and customize tools and media regarding accreditation requirements to identified members of the BIDMC community and clinical affiliates. This position supports the BIDMC Transparency agenda through regular updates and maintenance of the internal portal content and external website related to quality and safety.


* Acts as staff member to hospital wide accreditation readiness committee(s) and working subgroup contributor. Performs follow-up activities/project management support. Coordinates the dissemination of performance assessment and regulatory updates to appropriate medical center staff.

* Ensures that the accreditation readiness program is in place by coordinating 'mock surveys' and collecting required supporting documentation, data and action plans. Participates in the development of educational resources for the general staff regarding standard/regulatory updates.

* Screens and routes telephone calls as related to patient satisfaction/service excellence survey, performance assessment and/or Joint Commission standards.

* Coordinates the development of newsletters and other communication methods for the Office, including format, content development, and graphics. Maintains liaison relationship with peers at BID System hospitals and clinical affiliates of BIDMC by coordinating periodic (quarterly) joint sessions/meetings of key accreditation and quality and safety leaders; disseminates pertinent related materials.

* Conducts observation audit and chart review to support prioritized opportunities for improvement of projects related to annual operating plan and/or regulatory related topics using PDSA process. Contributes to the assessment of baseline performance and ensures improvement/corrective action plan durability. Manages data collection and recommends improvement to the process and improves workflow.


* Bachelor's degree required. Master's degree preferred.

* 3-5 years related work experience required.

* Experience with accreditation and licensing survey preparation activity in a health care setting.

* Advanced skills with Microsoft applications which may include Outlook, Word, Excel, PowerPoint or Access and other web-based applications. May produce complex documents, perform analysis and maintain databases.


* Bachelor's degree in clinical/healthcare management or related field preferred.


* Decision Making: Ability to make decisions that are guided by precedents, policies and objectives. Regularly makes decisions and recommendations on issues affecting a department or functional area.

* Problem Solving: Ability to address problems that are highly varied, complex and often non-recurring, requiring staff input, innovative, creative, and Lean diagnostic techniques to resolve issues.

* Independence of Action: Ability to set goals and determines how to accomplish defined results with some guidelines. Manager/Director provides broad guidance and overall direction.

* WRITTEN COMMUNICATIONS: Ability to summarize and communicate in English moderately complex information in varied written formats to internal and external customers.

* ORAL COMMUNICATIONS: Ability to comprehend and communicate complex verbal information in English to medical center staff, patients, families and external customers.

* KNOWLEDGE: Ability to demonstrate in-depth knowledge of concepts, practices and policies with the ability to use them in complex varied situations.

* TEAM WORK: Ability to act as a team leader for small projects or work groups, creating a collaborative and respectful team environment and improving workflows. Results may impact the operations of one or more departments.

* CUSTOMER SERVICE: Ability to provide a high level of customer service and staff training to meet customer service standards and expectations for the assigned unit(s). Resolves service issues in the assigned unit(s) in a timely and respectful manner.

Sedentary work: Exerting up to 10 pounds of force occasionally in carrying, lifting, pushing, pulling objects. Sitting most of the time, with walking and standing required only occasionally

Department Description
Under the direction of the Director of Regulatory Affairs, the Performance Assessment and Regulatory Compliance (PARC) team of BIDMC s Silverman Institute for Health Care Quality and Safety provides leadership for the overall assessment of performance and regulatory compliance at BIDMC, and serves as a resource to our institutional affiliates.

In alignment with strategic goals, regulatory and payer expectations throughout the institution, the team supports Senior Management in selecting targets for performance assessment, designing approaches for process improvement and systems to assess performance, as well as developing strategies for dissemination of information regarding performance.

The PARC Team coordinates and leads the medical center s accreditation compliance readiness and survey processes and works with multiple departments by incorporating standards and elements of performance into the everyday work of BIDMC by providing regulatory reference, education, technical/interpretation assistance, consultation and process improvement project management support related to regulatory readiness of Federal CMS Conditions of Participation, Mass DPH licensing regulations and The Joint Commission accreditation standards.

We direct the efforts toward transparency reporting on the internal and external BIDMC website for Quality and Safety Reporting ensuring information that is strategically aligned, useful, understandable and timely.

Each year PARC coordinates the Silverman Symposium , an all day event, which features a national guest speaker along with the "Celebrating Improvement Poster Session". The Poster Session celebrates the BID System's everyday work to improve quality and safety of care to patients and staff.

EOE Statement

Beth Israel Deaconess Medical Center is an Equal Opportunity Employer. We comply with the laws and regulations set forth in the linked poster:


Give your passion a home at Beth Israel Deaconess Medical Center. We have built our first-class reputation on clinical excellence, compassionate care, exceptional teaching and breakthrough research.. And there is no shortage of career opportunities to expand your expertise - we are always looking to grow our family with dedicated and compassionate individuals just like you.

Company Size:
5,001-10,000 Employees
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330 Brookline Avenue
Boston, MA 02215

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