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Oversees the daily continuous accreditation readiness for assigned facility(s). Coordinates department and facility accreditation compliance meetings, analyzes trends of performance metrics, identifies opportunities for improvement, develops action plans, measures success of these action plans, creates the records and follow-up metrics for each meeting and activity.
Job Responsibility:
Oversees the daily continuous accreditation readiness for assigned facility(s)
Coordinates department and facility accreditation compliance meetings, analyzes trends of performance metrics, identifies opportunities for improvement, develops action plans, measures success of these action plans, creates the records and follow-up metrics for each meeting and activity
Leads continuous accreditation readiness efforts and coaches others in the development of accreditation improvement capabilities
Provides direction to department and facility leadership in the planning of a systematic, organization-wide approach to continuous accreditation readiness
Maintains expert competence in accreditation standards and communicates relevant changes to appropriate leaders and staff
Maintains a close working relationship with facility leadership to optimize the quality and patient safety culture and to support constant state of readiness for accreditation reviews
Facilitates assessments, develops, implements and evaluates corrective action plans based on past surveys and preparatory tracer activities
Compiles and distributes compliance reports including appropriate action plans to oversight councils
Supports and guides the facility in continuous survey readiness efforts
Participates in the review, analysis and development of plans
Prepares reports and presentations
Assists leadership in defining key performance indicators and developing measurement tools to evaluate quality improvements
Utilizes facilitation skills (both team and individual), data analysis and statistical process control to effect improvement in quality and clinical outcome
Consults with and trains staff to implement monitoring and measurement tools, and data analysis techniques
Provides education and training on accreditation compliance and accreditation matters
Collaborates with staff to facilitate improvement teams to achieve facility and System quality and patient safety goals
Assists with system and regional quality initiatives
Requirements:
Bachelor's Degree required
Master's Degree preferred
RN or other clinical licensure preferred
Certification in healthcare quality, patient safety or related accreditation entity preferred, required within 1 year of employment
Works in an office environment
Requires walking, standing, long periods of sitting and computer use
Intact sense of sight and hearing required
Travels to facilities as needed
Must have current state driver's license
Nice to have:
Master's Degree
RN or other clinical licensure
Certification in healthcare quality, patient safety or related accreditation entity
What we offer:
Paid Time Off programs
Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
Flexible Spending Accounts for eligible health care and dependent care expenses
Family benefits such as adoption assistance and paid parental leave
Defined contribution retirement plans with employer match and other financial wellness programs
Educational Assistance Program
Premium pay such as shift, on call, and more based on a teammate's job
Incentive pay for select positions
Opportunity for annual increases based on performance