Accreditation Readiness Coordinator
JOB SUMMARY
Under general direction the Accreditation Readiness Coordinator focuses continuous compliance with accreditation and regulatory standards to ensure safe and quality patient care. Responsible for evaluation and coordination of all regulatory survey readiness and processes. Performs ongoing education, mock surveys, and other readiness tasks by designing and implementing a systematic approach to readiness and quality initiatives. Strives for superior performance by consistently providing a product or service to leadership and staff that is recognized as ultimately contributing to the patient and family experience. Recognizes and demonstrates understanding of patient and family centered care.
PRIMARY JOB RESPONSIBILITIES
- Provides leadership for accreditation readiness including survey coordination through routine needs assessments, assisting leaders to address areas of vulnerability, communication designed to promote best practices and areas of success, and ensuring that Memorial Healthcare’s policies and procedures are supportive of standards/regulations and ensure the safest patient care.
- Provides central expertise regarding accreditation and licensure standards. Identifies, communicates, monitors, and evaluates actions to comply with existing and new regulations.
- Ensures integration between accreditation activities and the quality, safety and performance improvement program.
- Provides education and collaborates with leadership, staff and physicians on patient safety and quality initiatives.
- Participates in hospital committees related to quality, accreditation readiness, and patient safety as appropriate.
- Designs, teaches, and evaluations education programs for quality and safety in collaboration with the Education department
- Demonstrates knowledge of and supports hospital mission, vision, value statements, standards, policies and procedures, operating instructions, confidentiality statements, corporate compliance plan, customer service standards, and the code of ethical behavior.
DEPARTMENTAL AND ADDITIONAL JOB RESPONSIBILITIES
1. Other duties as assigned.
JOB SPECIFICATIONS
EDUCATION
- Bachelors in healthcare related field or equivalent experience preferred.
- Associates degree in healthcare related field or equivalent experience required.
- Registered Nurse preferred, with a current license in Michigan
EXPERIENCE
- Five years of recent hospital experience in a clinical discipline required.
- Lean or Six Sigma education and training preferred.
- Two years of experience in regulatory and/or Joint Commission accreditation and quality strongly preferred.
ESSENTIAL PHYSICAL ABILITIES/MOTOR SKILLS
These physical requirements are not exhaustive and additional job related physical requirements may be added on an as needed basis. Corrective devices may be used to meet physical requirements.
- Sedentary Work: Frequently required to stand, kneel and crouch. On a daily basis may be required to move about, sit, climb stairs and bend. Is frequently required to lift and carry up to 20 lbs. May be required to push/pull/carry items between 20-100 lbs.
- Vision: Requires the ability to perceive the nature of objects by the eye. Near acuity: Clarity of vision at 20 inches or less. Midrange Acuity: Clarity of vision at distances of more than 20 inches and less than 20 feet.
- Motor Coordination: While performing the duties of the job, it is required to regularly perform functions that include using hand and finger movement, handle or feel objects, be able to use tools or equipment that requires reaching with hands and arms. Must be able to travel independently throughout the hospital; access patients/families including areas confined by space and/or equipment.
- Speaking/Hearing: Ability to give and receive information through speaking and listening.
ESSENTIAL TECHNICAL ABILITIES
- Proficiency using modern office, computer and telephone equipment as used by Memorial Healthcare.
- Proficiency in report creation using excel or other similar software.
- Proficiency in interpreting patient quality and other data.
ESSENTIAL MENTAL ABILITIES
- Ability to adapt and maintain focus in fast paced, quickly changing or stressful situations.
- Ability to read and interpret a variety of documents including, but not limited to policies, operating instructions, white papers, regulations, rules and laws.
ESSENTIAL SENSORY REQUIREMENTS
- Able to see for the purpose of reading information received in formats including but not limited to paper, computer, reports, bulletins, updates, manuals.
- Able to hear for work-related purposes.
INTERPERSONAL SKILLS
- Ability to interact with co-workers, hospital staff, administration, patients, physicians, the public and all internal and external customers in a professional and effective, courteous and tactful manner, at all times, physically, verbally and in all written and electronic communication.
- Required to remain calm when adversity is encountered.
- Open, honest, and tactful communication skills.
- Ability to work as a team member in all activities.
- Positive, cooperative and motivated attitude.
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