Quality/Accreditation Specialist II - Full Time - Days
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- Business (Non-Clinical)
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- 253622 Requisition #
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- Mar 14, 2025 Post Date
GENERAL SUMMARY:
Under limited direction, plans, organizes and maintains a process to ensure organizational compliance with regulatory standards and continuous survey readiness. Serves as an internal consultant for the interpretation of standards and functional measurement of compliance. Develops performance improvement plans with management/staff on an as needed basis. Interprets new regulations for education purposes and implementation efforts.
PRINCIPAL DUTIES AND RESPONSIBILITIES:
In collaboration with corporate and business unit leadership: Provides direction and oversight to regulations/accreditation compliance including but not limited to: TJC, DNV, State and Federal agencies (CMS) for hospital/system.
-Develops and monitors the org. infrastructure necessary to assure ongoing compliance with standards/regulations.
-Functions as a consultant, resource, educator to support the leadership team.
-Develops/implements an ongoing readiness plan to achieve continuous readiness/compliance
-Reviews and/or develops Policies/Procedures assuring compliance with regs.
-Manages associates and activities to ensure continuous operation and delivery of services
-Serves as a technical resource and assists in resolution of complex problems when necessary.
-Coordinates agency specific accreditation requirements (TJC/DNV)
-Assists depts.. in resolution of deficiencies by providing strategies that successfully meet the intent of the standards.
-Provides leadership/direction for on-site surveys and unannounced visits
-Provides routine reports to the quality committee; other committees regarding problem-prone areas, action plans, etc.
-Continuous learner regarding accreditation standards, Fed, state, local laws, regulations, compliance program, code of conduct as well as other p/p’s in order to ensure adherence in a manner that reflects honest, ethical and professional behavior. Develops and provides formal and informal education to all members of the health care team and support staff, to support continuous regulatory readiness and safe practices; shares best practices.
Demonstrate knowledge and understanding of the science of process improvement and provide formal and informal consultation to all members of the health care team and support staff, external customers (including students), and administrative staff in process improvement methodologies, performance measurement, sustain and spread methodologies. (PDCA; FMEA; etc)
Direct, facilitate and coordinate the design and implementation of business unit, regional and system wide clinical quality and patient safety initiatives, programs and projects; provide project management support to clinical improvement initiatives.
Possess strong analytical skills/problem solving techniques for conceptualizing, interpreting, developing, and implementing effective systems and processes. Demonstrate innovation and forward-thinking skills to promote positive outcomes.
Conducts self in a professional manner demonstrating leadership skills at all times/remains calm under pressure/stressful situations
Demonstrates excellent communication, discretion, and interpersonal skills for frequent contacts with internal customers and external stakeholders to persuade and negotiate results. Must possess strong teaching and counseling skills and the ability to inspire and build confidence in others to garner support.
Demonstrate effective leadership skills; acts as an ambassador of the organization with external agencies.
Demonstrates the ability to communicate, manage knowledge, mitigate error, and support decision making using information technology
EDUCATION/EXPERIENCE REQUIRED:
- Bachelor’s degree in Nursing or healthcare related field required , Master’s degree in health care field preferred; RN preferred
- Minimum 5 years hospital experience required; clinical/operational experience preferred
- Demonstrated knowledge of TJC, DNV, CMS Conditions of Participation required and familiarity with other accrediting, licensing and regulatory standards desirable.
- Evidence of continuing education in standards/regulations/training
- QI/PI Team member, lead or facilitator 1 – 3 years required
- Scope: Broad Business unit/multidisciplinary team experience (working with several departments, and//or “deep” experience within one service line, value stream, etc)
- Experience presenting to departmental, product line, and business unit leadership
- Knowledge of current healthcare issues and trends.
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Additional Details
This posting represents the major duties, responsibilities, and authorities of this job, and is not intended to be a complete list of all tasks and functions. It should be understood, therefore, that incumbents may be asked to perform job-related duties beyond those explicitly described above.
Overview
Under the leadership of President and CEO Robert G. Riney, Henry Ford Health is a
$6 billion integrated health system comprised of six hospitals, a health plan, and 250+ sites
including medical centers, walk-in and urgent care clinics, pharmacy, eye care facilities and
other healthcare retail. Established in 1915 by auto industry pioneer Henry Ford, the health system
now has 32,000 employees and remains home to the 1,900-member Henry Ford Medical Group, one
of the nation’s oldest physician groups. An additional 2,200 physicians are also affiliated with the
health system through the Henry Ford Physician Network. Henry Ford is also one of the region’s
major academic medical centers, receiving between $90-$100 million in annual research funding and
remaining Michigan’s fourth largest NIH-funded institution. Also an active participant in medical
education and training, the health system has trained nearly 40% of physicians currently practicing
in the state and also provides education and training for other health professionals including nurses,
pharmacists, radiology and respiratory technicians. visit HenryFord.com.
Benefits
Whether it's offering a new medical option, helping you make healthier lifestyle choices or
making the employee enrollment selection experience easier, it's all about choice. Henry
Ford Health has a new approach for its employee benefits program - My Choice
Rewards. My Choice Rewards is a program as diverse as the people it serves. There are
dozens of options for all of our employees including compensation, benefits, work/life balance
and learning - options that enhance your career and add value to your personal life. As an
employee you are provided access to Retirement Programs, an Employee Assistance Program
(Henry Ford Enhanced), Tuition Reimbursement, Paid Time Off, Employee Health and Wellness, and a whole host of other benefits and services. Employee's classified as contingent status are not eligible for benefits.
Equal Employment Opportunity/Affirmative Action Employer
Equal Employment Opportunity / Affirmative Action Employer Henry Ford Health is
committed to the hiring, advancement and fair treatment of all individuals without regard to
race, color, creed, religion, age, sex, national origin, disability, veteran status, size, height,
weight, marital status, family status, gender identity, sexual orientation, and genetic information,
or any other protected status in accordance with applicable federal and state laws.