Quality and Accreditation Manager Position Summary

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.

THE QUALITY AND ACCREDITATION MANAGER CANDIDATE WILL POSSESS THE FOLLOWING EDUCATION, LICENSE/CERTIFICATIONS, AND EXPERIENCE.

The requirements listed below are representative of the knowledge, skill, and/or ability required. In accordance with The Americans with Disabilities Act (ADA), it is possible that requirements may be modified to reasonably accommodate disabled individuals. However, no accommodations will be made which may pose serious health or safety risks to the employee or others or which impose undue hardships on the organization.

Minimum Education:

College Graduate, Bachelor�s Degree desired.

Minimum Experience:

• Experience in The Joint Commission program, Core Measures and Performance Improvement. Proficient with using the computer. Expert with word, excel and PowerPoint.

• Good leadership, communication, organization and planning skills. Able to act as a group facilitator and set priorities for action. Uses goal-directed approach in project management. Knowledge of statistical tools, data collection, analysis in presentation techniques. Excellent computer and presentation skills.

• Must be able to perform effectively in a stressful and fast paced work environment. Must have the ability to prioritize appropriately. Must be detail oriented and have the capacity to effectively multitask throughout the work shift. Must have excellent communication skills and the capacity to interact professionally with a variety of â��customersâ��, including but not limited to patients, families, co-workers, volunteers, and physicians throughout the work shift. Must possess the ability to function independently, yet productively as a cooperative team member with various work teams associated with the position. Must be compliant, with a willingness to follow all Hospital policies as well as the established practices, protocols and procedures of the position, department and applicable professional standards.

Required Certifications/Registrations/Licenses:

• A valid Permanent Multi-State RN License from the state in which you reside is required. 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.

Supervisory Responsibilities:

• Supervises the Outcomes Analysts and HOP Coordinator

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Employment practices will not be influenced or affected by an applicant�s or employee�s race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.