POSITION SUMMARY: The Accreditation and Patient Safety Director (APSD) establishes and sustains organization-wide processes and systems to maintain compliance with The Joint Commission (TJC) and Center for Medicare and Medicaid Services (CMS) standards. The function works with senior Leadership and the Leadership team (directors and managers) to direct and manage interdisciplinary teams to achieve continuous readiness with regulatory compliance. The APSM has the direct responsibility for assessing the organization?s compliance status, educating to The Joint Commission and CMS requirements, meeting regulatory deadlines and chairing the Continuous Survey Readiness Committee. This individual develops the goals and objectives for accreditation readiness and patient safety.

In addition, the APSD has responsibility for coordinating and overseeing the development of comprehensive patient safety improvement initiatives to reduce medical errors and healthcare incidents and s/he leads the hospital?s efforts related to promoting a just culture. The APSD works collaboratively with executives, administrators, doctors, and nursing to develop effective strategies that boost patient safety.  The APSD guides risk, clinical leaders, medical staff, operational leadership, and associates in a continual pursuit of patient safety improvement opportunities and promotes and vigorously supports a comprehensive culture of patient safety throughout the organization. The APSD has primary oversight of the patient safety program under the direction of the regional PSO and collaborates with leadership to develop policies and procedures affecting organizational patient safety. The APSM alerts leadership and the Quality Committee to real or potential system-based causes of negative outcomes to patient safety.

MINIMUM QUALIFICATIONS:

EDUCATION:  Bachelor?s Degree in health-related field or BSN required, or must actively be pursuing a BS/BA.  MSN preferred.  

CERTIFICATION/LICENSES: Current New Mexico or compact RN license preferred. Obtain the Certified Professional in Patient Safety (CPPS) credential through the National Patient Safety Foundation (NPSF) within two years.

SKILLS:

• Knowledge of TJC standards and Patient Safety core principles is essential
• Effective change agent
• Facilitative leadership skills
• Strong interpersonal skills including mentoring and coaching
• Strong problem solving ability
• Good analytical and mathematical skills are required
• Effective oral, written and presentation skills. Proficient computer, research and data management skills.
• Demonstrated ability to make public presentations to both large and small groups, and to articulate information or data to multiple audiences with varying degrees of knowledge and expertise

Evidence of capability should include:

• Strong leadership qualities (task completion, motivation)
• Project management, implementation and monitoring abilities
• Ability to establish and sustain processes and systems for continuous performance improvement
• Ability to plan, organize, direct, and manage the activities of others
• Ability to set, negotiate and achieve accountability for leadership and associate teams action, outcomes and deadlines with leadership and associate teams
• Possesses knowledge of regulatory and accreditation requirements, and national patient safety goals
• Ability to analyze and establish actions to achieve performance improvement
• Ability to analyze and report data in a meaningful and useful manner
• Ability to motivate others as individuals and as a team.
• Ability to communicate with a wide variety of audiences.
• Experience in collaborating with licensed independent practitioners (LIPs), LIP advisors and medical directors
• Working knowledge of quantitative analysis tools, MS Office applications including as Outlook, Word, PowerPoint, and Excel.
• Demonstrates patience and perseverance to accomplish clinical quality improvement

EXPERIENCE:  One year of management experience including experience in facilitating interdisciplinary team collaboration required.  Three years project management experience required, including experience or knowledge of performance improvement process, quality management activities, performance measures and evidence based practices

NATURE OF SUPERVISION:

-Responsible to: Executive Director of Performance Improvement with dotted line to Regional PSO for safety issues as needed.

ENVIRONMENT:

-Bloodborne pathogen:  A

Works in a clean, well-lighted, ventilated smoke-free environment.

PHYSICAL REQUIREMENTS: Working hours vary, with flexibility due to unexpected changes in schedule and emergencies.  Requires the ability to speak, listen, develop and communicate written materials.  Requires the ability to lift at least 20 lbs.

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About CHRISTUS Health

CHRISTUS HEALTH is an international Catholic, faith-based, not-for-profit health system comprised of almost more than 600 services and facilities, including more than 60 hospitals and long-term care facilities, 350 clinics and outpatient centers, and dozens of other health ministries and ventures. CHRISTUS operates in 6 U.S. states, Colombia, Chile and 6 states in Mexico. To support our health care ministry, CHRISTUS Health employs approximately 45,000 Associates and has more than 15,000 physicians on medical staffs who provide care and support for patients. CHRISTUS Health is listed among the top ten largest Catholic health systems in the United States.

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