Accreditation Director - RN Required

About the role

The Director of Accreditation will work collaboratively with the Executive Director of Patient Safety & Quality to oversee accreditation activities for the Acute Cares Services of Northeast Georgia Medical Center. This position is responsible for implementing a system and culture of continuous readiness for the hospitals and hospital outpatient departments in the system. A primary focus of the position will be supporting clinical and non-clinical departments in continuous compliance with DNV and ISO standards (including control of documented information and audits) and policy management for the system. He/She will support the Executive Director in ensuring the requirements of the Quality Management System (QMS) for System Level Acute Care Services are determined, implemented, and maintained.

Responsibilities

• Leads the continuous readiness and accreditation processes for the System Acute Care Hospitals, specifically CMS, DNV, Georgia Rules and Regs, and ISO.
• Reports and communicates findings, facilitating the completion of action plans, and monitoring.
• Works collaboratively with nursing, operations, Risk, and other departments to proactively identify areas of opportunity, and to implement systems to support improvement and continuous patient and survey readiness.
• Organizes the Accreditation team to support specialty-specific survey and certification activity.
• Manages policy and document control processes for system, including Policy Steering Committee oversight.
• Collaborates with others in the organization to promote consistent and standardized operations related to document control.
• Maintains administrative/strategic oversight for the document control system and oversees current and standardized operations within the system.
• Communicates and/or escalates unresolved issues, following established policy.
• Reviews and manages contracts pertaining to role functions, as assigned.
• Recognizes and operationalizes work needed to support annual pillars/goals.
• Collaborates with the Executive Director to determine fiscal requirements, preparing budgetary recommendations.
• Safeguards the competency, assessments, licensure, certifications, and other annual training of staff.
• Completes special projects or assignments, as requested.
• Learns and applies lean leadership principles, including supporting daily management system deployment and maintaining high proficiency in Quest for Excellence behaviors and tools.
• Affirms staff's level of performance through daily and periodic guidance, support, and resources to ensure high quality performance and achievement of organizational goals.

Requirements

Minimum Job Qualifications:

• Licensure or other certifications: Current license to practice as an RN in GA
• Education: Bachelors Degree
• Experience: Minimum of five (5) years of progressively experience in a hospital environment, including experience in management. Minimum of 5 years of Accreditation experience (preferably DNV and/or ISO) or related experience in a healthcare environment.

Qualifications

Preferred Job Qualifications:

• Licensure or other certifications: Preferred Licensure or other certifications
• Education: Preferred Educational Requirements: Masters Healthcare Administration, Business Administration or Organization Leadership.
• Experience: Preferred Experience: Experience with policy management.

Skills

Strong written and verbal communication skills
Excellent interpersonal and facilitation skills
Knowledge of local, state and national accreditation requirements and survey activities
Knowledge of ISO requirements, including control of documented information.
Ability to prioritize duties and projects; willing to work flexible hours to meet the needs of the department.

Benefits

Job Summary: The Director of Accreditation will work collaboratively with the Executive Director of Patient Safety & Quality to oversee accreditation activities for the Acute Cares Services of Northeast Georgia Medical Center. This position is responsible for implementing a system and culture of continuous readiness for the hospitals and hospital outpatient departments in the system. A primary focus of the position will be supporting clinical and non-clinical departments in continuous compliance with DNV and ISO standards (including control of documented information and audits) and policy management for the system. He/She will support the Executive Director in ensuring the requirements of the Quality Management System (QMS) for System Level Acute Care Services are determined, implemented, and maintained.

Pay

Not specified

Schedule

Varies