Director of Accreditation

Transcription

1 Executive Position Profile Director of Accreditation Community Health Accreditation Program This search is being conducted by: th Street NW, Suite 800 Washington, DC

2 Table of Contents Click any entry in this Table of Contents to go directly to that page. Click on the page number at the bottom of any page to return to these Contents. I. Organization Overview The Organization Deeming Authority Services & Programs Accreditation Explained Office Location CHAP s Purpose CHAP s Vision 2015 Board of Directors Website II. Position Description Scope of the Position Experience & Qualifications Key Responsibilities Personal & Professional Qualities III. About Vetted Solutions

3 I. Organization Overview Vetted Solutions is recruiting and evaluating candidates for the position of Director of Accreditation for the Community Health Accreditation Program, Inc. (CHAP). The position is based at the organization s headquarters in Downtown Washington, DC. The Organization The Community Health Accreditation Program is an independent, not-for-profit accrediting body for community-based health care organizations. Created in 1965 as a joint venture between the American Public Health Association (APHA) and the National League for Nursing (NLN), CHAP was the first to recognize the need and value for accreditation in community-based care. CHAP is the oldest national, community-based accrediting body, with more than 5,000 agencies currently accredited nationwide. In 1988, CHAP became a separately incorporated non-profit subsidiary of the NLN under the CHAP name. In 2001, it was spun-off by the NLN and became an independent, non-profit corporation. Deeming Authority The Centers for Medicare and Medicaid Services (CMS) granted CHAP deeming authority for home health organizations in 1992, followed in 1999 by hospice organizations, and the durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) category in This gives CHAP the regulatory authority to survey agencies providing service in a broad spectrum of health care areas to determine if they meet the Medicare Conditions of Participation and CMS Quality Standards. Moreover, CHAP has recognized deeming authority in all 50 states and approved status for licensure proxy in several states. CHAP accreditation is also recognized by most payers for credentialing in payer networks and CHAP provides assistance with communication and verification with payers as needed. Services & Programs Accredited CHAP accredits the following programs and services: n Home Health (deemed and non-deemed) n Hospice (deemed and non-deemed) n Home Medical Equipment n Pharmacy n Private Duty n Infusion Therapy Nursing n Public Health n Community Nursing Centers n Supplemental Staffing Services Structured to support myriad business types, CHAP s standards provide guidance and support to all community-based provider organizations from start-ups to seasoned national firms, from owneroperated single-location organizations to large multilocation organizations, from organizations focused on a single service line to multi-service-line organizations. Accreditation Explained Accreditation is a process, not an event. The process includes access to and adherence with a set of quality and performance standards geared to drive performance above the minimum standard. For organizations seeking to excel, the external standards and on-site validation and consultation by industry experts provide an excellent way to verify their excellence and, in so doing, improve 3

4 JCHAP their brand. CHAP provides support through a media kit to ensure its accredited organizations can also communicate CHAP accreditation to the community at large. The accreditation process actively involves the organization through the Self Study and Site Visit process. Furthermore, it engages the organization in continuous performance improvement through CHAP s Plan of Correction process, focus visits, and periodic renewal of accreditation. CHAP s broadly structured, nationally recognized Standards of Excellence provide insight into best practices for quality and performance. Since these Standards are not a narrowly prescribed operations manual, CHAP can provide standards that encompass an extremely broad set of guidance about the structures and processes that lead to quality outcomes. Office Location CHAP s main office is at 1275 K Street NW, in Downtown Washington, DC. The office is within walking distance of all six Metro lines: n 0.2 mile walking through Franklin Park from the McPherson Square Metro station, served by the Orange, Blue and Silver lines. n 0.4 mile from the Metro Center Metro station, served by the Orange, Blue, Red and Silver lines. n 0.6 mile from the Mt. Vernon Square Metro station, served by the Yellow and Green Lines. CHAP s Purpose The organization s purpose is to define and advance the highest standards of community-based care by: n Objectively validating the excellence of community health care practice through consistent measurement of the delivery of quality service; 4

5 n Motivating providers to achieve continuous improvement by adhering to standards of excellence; n Assisting the public in the selection of community health services and providers with demonstrated excellence; and n Leading by example through organizational excellence and quality performance. CHAP s Vision The organization states its vision as follows: CHAP will be the preferred accreditation services partner for community-based organizations Board of Directors u Katheen J. Dodd Chair Chair Emeritas, The Corridor Group, Inc. u Peggy Pettit Chair Elect Executive Vice President VITAS Healthcare Corporation u David E. Matyas Treasurer Firm Member, Epstein Becker Green u Warren P. Hebert, Jr. Secretary CEO, HomeCare Association of Louisiana u Elizabeth Buff Past Chair Senior Vice President, Quality Management & Clinical Excellence Retired Visiting Nurse Service of New York u Karen J. Collishaw, CAE President & CEO, CHAP, Inc. u Patricia T. Driscoll, BSN, MSN, JD Professor, Texas Women s University u Mabel Gonzales, JD Managing Member, Premium Consulting Group u Anne E. Johnson, MA Director, Policy Development & Accreditation Support BAYADA Home Health Care u Steven Landers, MD, MPH President & CEO, VNA Health Group u Daniel L. Maison, MD, FAAHPM Medical Director, Spectrum Health System u Barbara McCann Chief Industry Officer, Interim HealthCare, Inc. u Kevin P. McQueen Partner, BWB Solutions LLC u Nicole Silverman Senior Vice President, National Quality Forum u Maureen A. Spivack Managing Director/Co-Head Healthcare Group, KPMG Corporate Finance LLC u Sheila C. Strand, M.A. President Strand Communication Strategies, LLC Website The Community Health Accreditation Program, Inc., can be found online at: The organization has an additional online presence on Facebook, Twitter and LinkedIn. 5

6 II. Position Description Scope of the Position The Director of Accreditation of the Community Health Accreditation Program (CHAP) is responsible for daily operations related to all accreditation activities, as well as collaborating in the selection, training and evaluation of Site Visitors. The Director collaborates with other CHAP team members to ensure excellence in accreditation and customer service as well as CHAP continuous improvement. This person undertakes numerous oversight and supervisory activities in the pursuit of these goals. The Director reports to the Senior Vice President for Accreditation. The position has some flexibility in work schedules, and some work-related travel is required. Experience & Qualifications n A bachelor of science degree in nursing or in another health-related field. n A master s degree in nursing or a health-related field or at least eight years of commensurate experience. n At least eight years management experience, including staff supervision. n At least eight years experience in Medicare certified home health agencies and/or other community-based health care services delivery. n A strong, sound knowledge of at least one of the following: Medicare Conditions of Participation for Home Health; hospice; and Medicare supplier/ quality standards. n Experience in a CHAP-accredited organization is extremely helpful. n A sound knowledge and skills in quality-improvement activities and processes. n A high level of energy and focus on customer satisfaction. n Excellent written and verbal communications skills; effective interpersonal and team-building attributes. n At least intermediate computer literacy. n Demonstrated experience efficiently managing a professional staff, setting and maintaining clear and consistent standards for staff performance. n Proven consensus builder among diverse constituencies who is also an assertive decision maker. (Continued on the next page) 6

7 Experience & Qualifications (continued) n Experience developing and managing strategic plans, implementing goals in an organized fashion. n Familiarity with advocacy/government relations. n A good listener. n A charismatic, dynamic person who can communicate with a broad range of people, from providers to regulatory personnel. n A friendly, approachable, positive individual with good interpersonal skills. Key Responsibilities n Collaborates in the selection, training, supervision and evaluation of Site Visitors, including additional educational sessions as per annual plan and annual performance reviews. n Assists with new-hire orientation program and with welcoming new staff. n Reviews Site Visitor reports for accurate and consistent application of CHAP Standards of Excellence, as well as regulatory citations. n Finalizes accreditation findings and request-fororganization Plans of Correction in response to all deficiencies. n Performs review and acceptance of Plans of Correction, coaching organizations as necessary. n Responds to telephone calls from Site Visitors on site, to problem solve, coach and support critical thinking and appropriate decision making about application of CHAP and regulatory standards. n Plans for and executes Board of Review process, as well as timely follow-up of accreditation determinations and correspondence, and participates in Performance Improvement activities. n Ensures complete and accurate documentation of actions in agency hard copy and electronic records, including customer relationship management software. n Responds to telephone and s requests from organizations applying or about to apply regarding selection of agency-specific service standards for accreditation and interpretation of CHAP Standards and CHAP s process, standards and self-studies. n Collaborates with and assists other departments to ensure compliance with regulatory requirements and CHAP policies and to ensure CHAP accredited organizations improvement and satisfaction. n Identifies performance and knowledge deficits and assists with development and delivery of teleconference and webinar training to Site Visitors at least quarterly. n Responsible for in-services for site visitors and for helping site visitors with proficiencies in deficiency identification and documentation. n Assures appropriate projection of Site-Visit days for production of contracts and review of self-studies as well as site visits performed in accordance with CHAP timeliness standards. n Participates in strategic planning and reporting. n May participate in marketing and business development activity through attendance and presentations at trade shows and state association meetings. n Other duties as assigned. 7

8 Personal & Professional Qualities The successful candidate will possess a wide range of personality traits, work habits, and communication and social skills necessary to work effectively within the corporate environment. This person will have both personal and professional integrity, strong communication skills and a professional appearance and presentation. In addition, the qualified candidate will have a strong desire to succeed in a challenging environment. Other proficiencies and best practices for the highest performers include: n Integrity & compliance: Can be relied upon to act ethically, to safeguard confidential information and to adhere to the CHAP mission and core values. n Leadership: Ability to build senses of shared purpose and commitment in others. n Strategic vision & thinking: Ability to position the organization for the future, looking beyond present situation to conceptualize key trends and identify changing market demands. n Financial skills: Manages his or her part of CHAP s financial performance and understands key financial indicators. n Coaching & developing others: Guides others in performing effectively and provides others with development opportunities; provides direction without moving responsibility and lets others determine the best approach to executing assignments. n Managing performance: Assists others in setting goals that are challenging and aligned with the broader organization goals; monitors and evaluates others performance, provides feedback and reinforces behavior. n Recruitment & retention: Attracts, selects, and retains talented staff. n Relationship building: Networks outside and inside the organization and builds positive strategic relationships with key individuals and groups. 8

9 III. About Vetted Solutions V etted Solutions is a Washington, DC-based executive search firm specializing in recruiting and consulting for leading associations and nonprofits. We focus on senior staff and CEO positions with trade associations, professional societies, association management companies, nonprofit organizations and those organizations that serve them. For referrals or confidential consideration please submit a cover letter, resume and writing sample to: Jim Zaniello, President Vetted Solutions th Street NW, Suite 800 Washington, D.C jim.zaniello@vettedsolutions.com Evelyn Savage, Vice President Vetted Solutions th Street NW, Suite 800 Washington, D.C evelyn.savage@vettedsolutions.com For more information about us, visit our website, at and follow us on Twitter and LinkedIn. Vetted Solutions is a proud member of: Association of Executive Search Consultants 9