The Director of Accreditation and Regulatory is responsible for providing leadership, facilitation, and support to ensure organizational systems and processes comply with accreditation and regulatory standards at all Phoenix Children’s locations. Responsibilities include, but are not limited to, maintaining current knowledge and expertise of accreditation/regulatory standards and trends, directing the planning, implementation and evaluation of accreditation/regulatory activities, leading organizational initiatives and partnering with key stakeholders to ensure compliance with regulations/standards, developing communication plans to educate/update leaders and staff related to accreditation/regulatory topics, creating and implementing a structure to foster an environment of continual readiness, including all pre/peri/post survey activities, and managing and overseeing the budget to ensure the effective use of resources.

• Leads, establishes, implements, and evaluates organizational systems and processes to attain/maintain accreditation status and regulatory readiness, while supporting safety and quality goals of the organization.
  
  1. Develops strategies to evaluate the organization’s alignment and performance with accreditation/regulatory standards.
  2. In collaboration with Organization and OGC Leadership, facilitates the development and implementation of a strategic plan that includes the process to identify gaps as well as areas that need improvement enterprise wide. Aligns with current initiatives or partners with leaders to establish new priority areas. Provides leadership and staff information/education related to accreditation/regulatory issues, on-site surveys, areas of risk, changes in standards/regulations and strategies to improve performance.
  3. Anticipates changes in national Regulatory and accreditation trends. Maintains current knowledge and expertise on standards, regulations, requirements, and interpretive guidance documents.
  4. Supports and assist organizational leaders to maintain an environment of continual assessment and improvement. Promotes sustainability of improvement efforts, addressing new risk(s) that may include patient/staff/visitor safety.
  5. Guides and directs key stakeholders in the development of performance measures related to accreditation/regulatory standards, quality dashboards (QAPI) and other measures associated with improvement.
  6. Leads the work of executive committees that support Regulatory and Accreditation efforts. Collaborates with senior leaders, leaders, and front-line staff to maintain organizational focus on accreditation/regulatory issues and performance improvement.
  7. Leads the development of processes and infrastructure to communicate and respond to external organizations related to accreditation/regulatory survey findings or reviews as required.
  8. Provides expert guidance and mentors teams related to the quality assessment, performance improvement, clinical safety science, evidenced based practice and Phoenix Children’s methodologies in relation to accreditation/regulatory activities.
  9. Leads the development and implementation of a structure that fosters all pre/peri/post survey activities.
• Directs activities that support accreditation and improves accreditation and regulatory readiness.
  
   1. Develops methodologies to assess areas of strength, opportunities for improvement regarding accreditation/regulatory readiness and provides ongoing data and feedback to appropriate staff organization wide.
  2. Allocates resources based on level of risk, prevalence and assessed need.
  3. Acts as a content expert related to accreditation/regulatory requirements and advises groups if established processes are congruent with accreditation/regulatory requirements.
  4. Mentors organizational leaders in evaluating regulatory alignment and readiness to increase system level knowledge and performance.
  5. Recommends, participates on, and/or maintains awareness of the work of teams focused on processes governed by accreditation/regulatory standards.
• Engages in ongoing learning and educates others within the organization regarding accreditation/regulatory requirements.
  
  1. Identifies learning/training needs and professional development of the Accreditation and Regulatory staff.
  2. Identifies and addresses learning needs of organizational leaders and staff related to accreditation/regulatory readiness.
  3. Collaborates with other system level resources and leaders (e.g. Education, HR, Department) to meet educational needs.
  4. Provides education to key groups on current trends related to accreditation/regulatory standards.
  5. Initiates continual self-learning to increase knowledge related to quality improvement methods, safety science, high reliability principles, tools, processes, measurement strategies, and accreditation/regulatory requirements.
• Leads and manages the operations of the Accreditation and Regulatory program.
  
   1. Develops and maintains oversight of the department operating budget.
  2. Manages resources effectively and plans for resources needed to support prioritized programs.
  3. Leads staff to establish departmental priorities based on risk.
  4. Identifies educational/skill needs for staff and provides or coordinates continued education.
  5. Engages accreditation and regulatory readiness staff in continual improvement of department programs.
• Performs miscellaneous job related duties as requested.
  

To advance hope, healing and the best healthcare for children and their families

Phoenix Children's will be the leading pediatric health system in the Southwest, nationally recognized for exceptional care, innovative research and advanced medical education.

We realize this vision by:

• Offering the most comprehensive care across ages, communities and specialties
• Investing in innovative research, including emerging treatments, tools and technologies
• Advancing education and training to shape the next generation of clinical leaders
• Advocating for the health and well-being of children and families

• We place children and families at the center of all we do
• We deliver exceptional care, every day and in every way
• We collaborate with colleagues, partners and communities to amplify our impact
• We set the standards of pediatric healthcare today, and innovate for the future
• We are accountable for making the highest quality care accessible and affordable