Quality and Accreditation Coordinator - Full Time - Days

Position Summary:

Under the leadership of the Quality Director, the Quality and Accreditation Coordinator is an active member of the Quality team that delivers professional services and support that is consistent with the strategic vision, goals, philosophy and direction of Quality department and Crisp Regional Health System. The Quality and Accreditation Coordinator in support with the Quality Director has responsibility for developing and implementing patient safety initiatives assuring success of continuous quality enhancements, assessing hospital departmental data, and coordinating PI activities to meet regulatory requirements. This role is responsible for the appropriate use of quality tools (e.g., root cause analysis, FMEA). The Quality and Accreditation Coordinator assure compliance with regulatory standards and ensures they are continually upheld.   

Basic Qualifications:

• Education:

Bachelor’s degree in Management or Business related field, Master’s degree preferred. An Associate’s or Bachelor’s degree in an allied health or nursing field preferred.

• Experience:

Requires a minimum of three years of work-related experience or an equivalent combination of education, training, and experience. Management experience preferred. Joint Commission accreditation experience preferred.

• Licensure, Registrations & Certifications:

If degree is in a nursing field, a current state license as a Registered Nurse or a Licensed Practical Nurse is required. Along with a listing of good standing with the state’s Department of Professional Credentialing.

        Certified Professional in Healthcare Quality (CPHQ) obtained within three years of employment.

Essential Job Responsibilities:

• Responsible for oversight and direction of the organization’s quality program, including quality improvement initiatives and regulatory compliance.
• Assumes responsibility for safety, and performance improvement as part of CRHS’s efforts to provide quality care and services.
• Applies the principles of continuous quality improvement in delivery of services, through measuring, monitoring and assessing processes and systems.
• Leads the organization in High Reliability Organization (HRO) principles application as applicable.
• Facilitates and directs organizational wide compliance and continuous readiness with statutory mandates, regulatory requirements and accreditation standards of professional organizations. (i.e. TJC).
• Actively contributes to and works toward hospital wide improvement in meeting core measures, patient safety and service excellence goals.
• Ensures that policies and procedures are current and meet all current laws, regulations and standards of care; monitor dates of review and revisions, revise as appropriate.
• Acts as a liaison between department directors and the Quality department in the creation of data collection tools and assists with analysis with data and identification of opportunities for improvement
• Actively participates in the Quality Operations committees, and other patient safety meetings to improve patient care or the patient care experience.
• Performs other related job duties as assigned.