Quality and Accreditation Coordinator

This employee is an expert on The Joint Commission regulatory standards. Responsible for Continuous Readiness Program including hospital wide processes, active audit and inspection program for survey preparedness and compliance with TJC, CMS and other pertinent regulatory standards. Provides house wide support for education regarding regulatory standards. Serves as TJC coordinator for the hospital in conjunction with DCQI. Provides supervision, guidance and assistance with overall implementation, integration and coordination of hospital Performance Improvement program. Is able to independently lead PI processes house wide. Coordinates evidenced based medicine and performance improvement activities of the clinical staff. Assist with development and implementation of strategies aimed at improving performance. Participates in committees associated with Core measures and quality initiatives as needed. Serves as consultant to the Medical Staff Committees and Department Managers. Coordinates with physicians in real time and retrospectively on evidence based medicine and regulatory standards compliance. Participates in the hospital policies and procedures committee and any other committee as assigned. Assists DCQI in the day-to-day operations of the hospital.

• Compliance with regulatory and accrediting agencies - Monitors pertinent state and federal regulations, standards, and guidelines, as well private initiatives in quality management and improvement analyze implications and inform medical staff, administration and governing board leadership of evolving trends and requirements for compliance.
• Communication and reporting - Assists in dissemination of PI findings and reports as needed for Department Director meetings or through other forms of communication such as house-wide script.
• Data collection and analysis - Provides support for data collection and analysis, including the ongoing systematic screening of data sources and special studies to evaluate patient care quality and impact of corrective actions taken.
• Education and support - Develops and coordinates education of staff and physicians on PI initiatives and Programs.
• Policy and procedure management - Facilitates department directors’ education on Policy and procedure data base, use and requirements of system.
• Performs related duties as required.

• Required:
  • Experience: 
    • Experience in The Joint Commission program, Core Measures and Performance Improvement.
    • Proficient with using the computer
    • Expert with word, excel and PowerPoint.
  • Licensure/Certification: 
    • RN License or equivalent combination of advanced education and related work experience
    • Any RN license must be valid Permanent Multi-State RN License from the state in which you reside
    • Should you hold a RN license from another Compact state, you are required to apply for and obtain a Multi-State RN License from the state in which you reside within 30 days.

• Preferred:
  • Education: College Graduate, Bachelor’s Degree

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