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Role Description

The Sr Associate Director for Standards Interpretation Group will assist the Director of Standards Development and Interpretation in the support of daily operations for the department. In addition to performing daily operations tasks of Associate Directors, they will be responsible for leading small projects within the department. They will address mild to moderate concerns involving internal and external customers. In addition, they will provide interpretation of all Joint Commission standards with special emphasis on standards issues related to specific settings, professional disciplines, or accreditation programs (e.g. OME, NCC, ALC). Combines systems analysis skills with in-depth general and program-specific knowledge to evaluate health care organizations’ compliance and ability to provide high quality, safe patient care. They will partner with program development revision of standards and survey/review processes. Participates in ongoing accreditation/certification services and special projects. Serves as faculty for field staff and other education programs and represents Joint Commission as liaison to various professional organizations. In conjunction with operations team, ensures that accredited organizations receive excellent customer service and that their accreditation, certification needs of healthcare organization’s needs are met.

Responsibilities

• Responsible for setting day to day operational objectives for team.
• Provide resolution for mild to moderate complexity operational concerns.
• Serve as a resource to SIG Associated Directors for policies, procedures and practices associated with Accreditation/Certification Program Development and Accreditation Management operations.
• Provide operational support for Standards Interpretation Group to assure achievement of departmental goals.
• Evaluate on-site survey issues to determine level of risk and need for immediate threat declaration.
• Conduct Associate Director Performance Evaluations.
• Provides guidance on and expert interpretation of Joint Commission standards and Medicare requirements, professional standards of practice, and law and regulation to internal and external customers including but not limited to: field representatives, service teams, Office of Quality and Patient Safety (OQPS), other divisions, Joint Commission Resources (JCR) field staff, accredited organizations, those seeking accreditation or certification, professional associations, governmental agencies, consultants, educators and students.
• Supports the entire accreditation/certification process through the development, review and analysis of survey reports and outcomes, interactions with the field representatives and accredited customers, serving as a resource to the account executives and making recommendations on accreditation/certification decisions to the Accreditation Council.
• Works closely with OQPS to provide support to the complaint analysis process through: the review of complaints providing information on potential standards non-compliance; the development of assessment maps to guide the surveyor(s) conducting OQPS surveys and participates in preparatory conference calls as needed.
• Provides leadership and guidance to the Accreditation and Certification Operations (ACO) service teams in all aspects of the accreditation process through clinical expertise and customer relationship management.
• Serves as a role model in the support of and implementation of enterprise, division and departmental mission and initiatives utilizing Robust Process Improvement (RPI) tools and strategies as indicated. Leads and/or participates in internal work groups to identify and implement improvements to our internal processes.
• Provides direction and guidance to internal and external customers in the consistency of standards interpretation through inquiry and frequently asked questions (FAQ) management processes, educational offerings, publications and media and social networking opportunities. Serves as faculty for field representative training (both TJC and JCR), Speaker’s Bureau and JCR seminars and workshops. Participates in strategic business unit (SBU) teams or other program specific committees and work groups, as assigned.
• Effectively communicates with internal and external customers in a respectful, constructive and collegial style. Consistently provides excellent customer service to all internal and external customers.
• Embraces The Joint Commission culture of safety and serves as a role model in incorporating the SIG Department Guidelines into daily work and interactions.

Qualifications

• Registered Nurse required.
• Masters Degree required.
• 5+ years of progressive leadership or supervisory experience and current clinical knowledge.
• Must be able to lift 25 pounds.
• Must be able to climb stairs and ladders and work in settings with infectious diseases.
• Must be able to travel up to 20% of work time.