Works independently under the general to ensure compliance with accreditation and regulatory standards. Responsible for development, implementation, and evaluation of processes to support ongoing compliance with The Joint Commission, Maryland Department of Health, Centers for Medicare & Medicaid (CMS) and other regulatory bodies as required. Leads and works collaboratively with internal and external partners to achieve continuous regulatory and accreditation compliance, positive survey outcomes, and a safe environment for patients and staff.

Manager Accreditation (RN) - Quality Management

Full-time - Day Shift

Experience the highest level of appreciation at UM Baltimore Washington Medical Center — named Top Workplace in the Baltimore area by The Baltimore Sun two years in a row (2019 & 2020); Top Workplace in the USA for 2021! As part of the acclaimed University of Maryland Medical System, our facility is one of three ANCC Pathway to Excellence® designated hospitals in Maryland. UM BWMC features one of the state’s busiest emergency departments, as well as a team of experts who care for our community and one another. 

The University of Maryland Baltimore Washington Medical Center (UMBWMC) provides the highest quality health care services to the communities we serve. Our medical center is home to leading-edge technology, nationally recognized quality, personalized service and outstanding people. We have 285 licensed beds and we’re home to 3,200 employees and over 800 physicians.

Our expert physicians and experienced, compassionate staff are connected to medical practices in the local community as well as at University of Maryland Medical Center in downtown Baltimore. For patients, this means access to high-quality care and research discoveries aimed at improving Maryland’s health. Our physicians and nursing staff specialize in emergency, acute, medical-surgical and critical care. In addition, our medical center is home to many Centers of Excellence, offering expert outpatient health care.

Bachelors of Science in Nursing or equivalent Health Care Field (required)

Masters of Science in Nursing or equivalent Health Care Field (preferred)

Five (5) years’ of previous clinical experience in hospital including experience with facilitating and leading safety and quality improvement initiatives is required. Previous experience in quality or safety role preferred.

Current Maryland license in good standing as Registered Nurse (required)

CPHQ (preferred)

All your information will be kept confidential according to EEO guidelines.

1. Assumes primary responsibility for, organizes, coordinates and leads activities and improvements related to accreditation and regulatory compliance. Responsible for the development and coordination of action plans and the monitoring of action plans in order to sustain improvements.
2. Collaborates with all staff, clinical professionals and administrative leadership to foster a culture of accreditation readiness thereby assuring safety, quality care and regulatory compliance.
3. Harmonizes improvement efforts with other activities in the organization utilizing knowledge of accreditation standards. Participates in safety, environmental, and leadership rounding. Works with Leaders and Physicians to organize and incorporate accreditation readiness communication into standing meetings and huddles.
4. Leads clinical audits/assessments and chart reviews to identify accreditation and compliance issues. Utilizes data from a variety of sources to identify opportunities to improve the systems in the delivery of care. Validates electronic data as appropriate.
5. Leads, coordinates and facilitates RCAs and FMEAs in response to sentinel/adverse events.
6. Conducts tracers and identifies accreditation and regulatory compliance issues at unit, department, and organizational level, and provides timely and actionable feedback to physicians and staff. Collects, enters, aggregates, and trends tracer findings, and presents results to unit, departments, and leadership. Develops targets and improvement plans when necessary. Trains staff and leaders in tracer activities. 
7. Participates in onsite visits by regulatory agencies including “for cause visits” and “complaint investigations”.
8. Serves as the representative for external interaction with accrediting and regulatory bodies. Primary point of contact for all agencies during announced and unannounced surveys. Chairs the Regulatory Readiness Committee, Regulatory Oversight Committee and Other Committees as assigned. Manages official communication with accrediting and regulatory bodies, assuring timely completion of all submissions, including (not limited to) applications, periodic reviews, corrective action plans, and responses to inquiries and survey findings.
9. Develops and leads innovative new programs to increase involvement of front-line staff and all care team members in accreditation related initiatives. Builds strong working relationships with all clinic staff and management to help achieve compliance.
10. Identifies needs for educational programs; develops and delivers multidisciplinary educational sessions, or facilitates and coordinates obtaining training sessions utilizing knowledge of patient safety risks, quality, regulatory standards and policies. Participates in the education of medical staff, employees, and leadership.
11. Serves as the expert regarding Joint Commission and CMS standards, and stays abreast of changing regulatory requirements. Maintains current knowledge of certification requirements as applicable to the organization.
12. Coordinates meetings, creates agendas, and determines membership for regulatory related meetings.
13. Gathers metrics where applicable.
14. Does related work as assigned