Director of Accreditation
About The Position
The Director of Accreditation and Certification implements, directs and facilitates activities that support the institution's ability to achieve and remain a successfully accredited health care organization that is continuously ready for patients every day. For accreditation and certification survey related activities, the director will serve as the on-site survey leader, as a resource and consultant to the organization, as a liaison between the hospital and the accrediting organization, and as an expert in continuous improvement processes. This role reports to the Associate Vice President of Accreditation and Quality and supervises accreditation team members.
Requirements
- Master's Degree in Nursing or a healthcare-related degree required
- 7 to 10 years of applicable healthcare experience
- 5 years in direct patient care nursing
- Related experience with quality measures accreditation standards, and related compliance processes
Responsibilities
- Directs all organizational Continuous Survey Readiness Activities which include managing, facilitating, or coordinating the following activities
- Directing the completion and submission of accreditation/certification administrative activities in collaboration with operational partners
- Coordinating an ongoing readiness assessment
- Updates accreditation and certification portal to reflect hospital’s services
- Prepares for all accreditation and certification on-site surveys (together with real-time coordination, facilitation and follow-up)
- Preparing the organizational response to unannounced accreditation on-site surveys
- Provides staff education andtraining
- Consults on and interprets standards (CMS, New York State Department of Health and Accreditation)
- Communicates accreditation/certification/regulatory information
- Collaborates with others in continuous improvement processes, including data collection, analysis and reporting
- Collaborates with others in policy and procedure development and review
- Development of tools(checklists, data collection forms) for conducting individual auditsa nd assessment surveys
- Oversees the collection and distribution of audit data
- Collaborate with the professional education department on the development and distribution of materials related to standards compliance
- Development and distribution of periodic communications to update organizational leaders and staff on new quality/safety issues or initiatives, on-site survey information and any changes to standards or the interpretation of accreditation/certification standards
- Participates in employee orientation activities as required by the organization
- Provides education to staff as needed regarding new quality/safety initiatives
- Conducts periodic meetings with managers to update their knowledge of accreditation standards and regulatory/organizational issues and trends uncovered during readiness activities
- Facilitates annual collection of information/data required to participate in Leapfrog’s Hospital Grade. The Director will communicate as needed with relevant staff and leadership to assure successful participation.
- Facilitates ad hoc performance improvement groups focused on clinical and accreditation standard compliance.
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What This Job Offers
Job Type
Full-time
Career Level
Director
