Quality and Accreditation Coordinator

Overview

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 consistent with the strategic vision, goals, philosophy and direction of the Quality department and Crisp Regional Health System. The Coordinator supports the Quality Director in developing and implementing patient safety initiatives, ensuring continuous quality improvements, assessing hospital departmental data, and coordinating performance improvement (PI) activities to meet regulatory requirements.

This role uses quality tools (e.g., root cause analysis, FMEA) and ensures regulatory standards are continually upheld.

• 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:
  
  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 the degree is in a nursing field, a current state license as a Registered Nurse (RN) or Licensed Practical Nurse (LPN) is required, along with a good standing listing with the state’s Department of Professional Credentialing. Certified Professional in Healthcare Quality (CPHQ) obtained within three years of employment.

• 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 the delivery of services by 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 (e.g., 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 applicable laws, regulations and standards of care; monitors dates of review and revisions and revises as appropriate.
• Acts as a liaison between department directors and the Quality department in creating data collection tools and assists with data analysis 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 duties as assigned.