Quality/Accreditation Specialist II - Full Time - Days

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