I. PURPOSE OF THE JOB
To work under the supervision of the Director of Quality Initiatives to provide direction to departments to achieve and maintain accreditation, certification and licensure, and to assist the Department Director in the planning and management of the organization-wide Patient Safety Quality Management Program. Assure appropriate systematic monitoring and evaluation of the delivery of patient care for all departments (medical staff and hospital) that meet the requirements of governing bodies, external agencies and the hospital’s mission and values.
II. ESSENTIAL FUNCTIONS
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Serve as a professional resource to interpret and implement Joint Commission standards, and the Pennsylvania Department of Health and Centers for Medicare and Medicaid regulations applicable to the hospital environment. (50%)
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Serve as the hospital liaison to Department of Health and The Joint Commission for survey applications, survey coordination activities, Joint Commission application and action plan submissions. (20%)
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Assist the Department Director in the development, planning, and management of the organizational (hospital and medical staff) Patient Safety Quality Management Program that systematically monitors, evaluates and improves the safety and the delivery of patient care, and meets the requirements of governing bodies, review agencies and the hospital’s mission and values. (15%)
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Advance a culture of safety within the organization through the Patient Safety Quality Management Program, and assure compliance with regulations promulgated by the State Department of Health and the Patient Safety Authority. (15%)
Job Qualifications:
IV. QUALIFICATIONS:
A. Education: Bachelor Degree in Nursing, Master Degree in Nursing, Health Administration or related
field, preferred.
Certification: CPHQ (Certified Professional in Healthcare Quality) / CPPS (Certified Professional in
Patient Safety) preferred.
B. Experience: Minimum of three years in accreditation / regulatory environment
C. Other Skills: Certification and Pennsylvania license
Knowledge and experience with licensing regulations and accreditation standards
Knowledge and experience in improvement theory and systems functionality
Knowledge of system design principles and issues regarding patient safety
Ability to facilitate multi-disciplinary teams
Effective change agent
Use of Information systems and PC literacy
Proficient in oral and written communication and interpersonal skills
Strong analytical and organizational skills
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