Accreditation & ISO Coordinator
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About The Position
The Accreditation/ISO Coordinator plays a crucial role in the hospital's continuous accreditation and regulatory readiness program. This position is responsible for providing direction and oversight for regulatory and accreditation compliance, including DNV, ISO 9001 Quality Management System Requirements, and compliance with State and Federal agencies. The coordinator assists in maintaining preparedness for accreditation and licensure surveys, ensuring that the organization meets all necessary standards and requirements. In this role, the coordinator will conduct gap analyses and develop evidence-based corrective action plans to ensure compliance with regulatory standards. They will participate in monthly accreditation education sessions, which include planning agendas, taking minutes, and delivering presentations as needed. The coordinator will also organize an interprofessional team to serve as chapter leads for accreditation standards, ensuring that all departments are aligned and informed about the accreditation process. Additionally, the coordinator executes the survey readiness program, which includes preparing for mock surveys and tracer methodology. They provide consultation to organization leaders on survey readiness and NIAHO standards, updating them on new standards and ensuring effective communication of expectations. The coordinator is also responsible for the accuracy and timeliness of submitting corrective action plans to external agencies and internal stakeholders. Furthermore, they will develop the ISO internal audit strategy and oversee the implementation of the ISO strategic plan.
