Scope of Position

The position provides strategic leadership and oversight for all accreditation, regulatory compliance, and life safety activities across The James Cancer Hospital and Solove Research Institute. It is responsible for conducting assessments, coordinating education, managing surveys and responses, and implementing systems to monitor compliance with evolving standards. The role prepares and submits required documentation to local and national regulatory bodies, evaluates the effectiveness of corrective actions, and supports continuous quality improvement to ensure safe, highâ‘quality, and compliant healthcare delivery. It ensures organizational policies align with legal and regulatory requirements and provides education on policy updates. Serving as a subject matter expert for the Comprehensive Cancer Center program, the leader interprets standards and regulations from bodies such as the Joint Commission, Ohio Department of Health (ODH), Centers of Medicare and Medicaid Services (CMS), and Columbus Public Health, while also supporting additional accreditations including the Commission on Cancer. The position oversees hospital licensing, coordinates ODH-related activities, and leads Emergency Preparedness efforts for the organization.

Position Summary

The Associate Director of Accreditation and Compliance is responsible for management of departmental operations, evaluation of employee performance, ensures the department demonstrates customer satisfaction and strategic, operational planning and program development. Has a strong working knowledge of ongoing monitoring techniques (including total quality management principles, tools, & techniques); clinical operations in hospital & outpatient settings.

The Associate Director is responsible for ensuring that the facility remains in compliance with Joint Commission, State and Federal standards with oversight and responsibility for all regulatory body surveys, i.e., Joint Commission, State Licensing and Reviews, CMS Validation Surveys, Health Department, local regulatory reviews (fire marshal), and any other regulatory activity that involves the facility. This responsibility includes staying current with Joint Commission, state, and local standards, educating facility staff about standards, and preparing the facility for surveys.

Plans and coordinates accreditation and regulatory compliance activities to assure safe, high quality and regulatory compliant healthcare delivery. This includes involvement in the development and implementation of hospital-wide performance improvement plans and valuation of effectiveness of corrective actions for identified problems and continuous quality improvement activities.

Responsible for the overall leadership of implementation of the organizations Accreditation and Regulatory Plan; evaluation of the quality of care provided to people receiving support from all organizational entities; and the organization-wide monitoring, analysis, and improvement of program processes. Also responsible for coordinating and directing varied functions in the programs across the organization to provide an integrated approach to quality improvement and management related to regulatory activity.

Responsible for ensuring policies are compliant with legal standards, the rules and regulations of regulatory agencies, and that education is provided to the organization on policies and procedures updates.

This position coordinates and collaborates with the Enterprise Emergency Preparedness and Life Safety Program at The James.

Minimum Qualifications

• Master's Degree in Nursing or a Healthcare related field or equivalent combination of education and experience.

• 6 years experience in accreditation survey preparation and coordination.

Preferred

• 5 years patient care experience

• 3 Years in leadership

• Hospital or Outpatient management experience, including but not limited to regulatory & licensing, accreditation, performance improvement, risk management and quality assurance in an acute care hospital.

• Current experience (within the last three years) with regulatory survey process and development of regulatory plans of correction/action plans.

• Knowledge of medical staff oversight/credentialing

• Current licensure if applicable

Ongoing: This person must demonstrate competency to meet essential job functions and the ability to adapt to the rapid changes that occur in the health care setting. Maintains and seeks new knowledge related to regulatory oversight, emergency preparation, current policies, procedures, and protocols. Must meet mandatory educational and health requirements. Experience in databases, spreadsheets, and graphics required.

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