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Schedule/Status:

8:00am-4:30pm; Full-time

Standard Hours/Week:

40

General Description:

Under the general supervision of the Director of HIM and Quality, the Accreditation and Patient Safety Coordinator coordinates the ongoing development of a continuous performance improvement culture that includes the coordination of all functions related to accreditation, surveys, and disease-specific certification processes. Serves as the liaison for external accreditation agencies. Serves in an advisory capacity to the medical staff, hospital departments, clinics, medical offices, committees and Performance Improvement/Patient Safety Committees. Is familiar and acts as a resource for other teams in applying and using Quality Improvement/Performance Improvement/Process Improvement methodology and statistical tools. Is knowledgeable regarding core measures, appropriate care measures, and pay for performance measures. Has a working knowledge about data reports and analysis to promote improvement.

Key Responsibilities:

Acts as accreditation agency/organization liaison, coordinates accreditation preparation work teams, and assists with the continued compliance with standards to attain accreditation with high scores. This includes the Joint Commission, the Disease Specialty Certification Programs, Leapfrog, and other regulatory agencies.*

Provides assistance in monitoring compliance with standards and regulations, providing a summary of trended performance improvement data to hospital/clinic committees, medical staff committees, and the Board of Directors.*

Actively participates and supports the Patient Safety initiatives ensuring compliance with the requirements. Works with staff to develop and implement corrective action plans to ensure ongoing compliance. Monitors for effectiveness implemented corrective action plans and works with staff to modify where applicable.*

Performs hospital, clinic, and medical office environmental rounds on an ongoing basis to monitor for compliance and to use it as an opportunity to educate staff.*

Assists and leads managers, directors and medical staff committees with problem identification, analysis, and implementation of process change. Establishes and maintains files of performance improvement activities as they relate to the accreditation process.*

Provides ongoing Performance Improvement education, accreditation and disease-specific standards education, regulatory agency requirements for staff; provides just in time training as identified and needed.*

Utilizes and supports other areas with performance improvement tools and methodologies. Develops meaningful evaluation methodologies and effectively articulates them. Aids in the initiation of performance improvement/quality improvement/process improvement teams and serves as mediator or facilitator and project team member as they relate to the accreditation process.*

Ensures data security and confidentiality. Knows fire, disaster, and safety procedures and regulations as pertains to the work area.

Performs similar or related duties as assigned.

Requirements

Formal Education:

Bachelor’s Degree or Master’s Degree in health-related field preferred – Nursing preferred; Associate Degree required

Work Experience:

Three to Five years in healthcare; one-year minimum experience in hospitals working with Quality and Performance Improvement initiatives; accreditation agency experience or experience with accreditation agency surveys considered a plus; one year management experience preferred

Required Licenses and Certifications:

Current State of Florida RN Licensure, CPHQ, AHIMA, JCIP, or comparable credentialing.