Manager, Accreditation & ISO
Apply NowCompany: Piedmont Healthcare
Location: Conyers, GA 30094
Description:
Description:
This position supports both Piedmont Rockdale and Piedmont Walton
JOB PURPOSE:
Responsible for leading and driving safety and quality performance improvement initiatives and action plans primarily related to hospital accreditation and ISO certification as identified by the internal audit process, accreditation survey results and /or determined by Quality, Safety and Service (QSS) Committee. Manages continuous survey readiness for assigned Piedmont entities accredited by DNV. Promotes a culture of continuous improvement through use of Lean methodology, coaching, tools, data analysis, reliability, sustainability and spread. Responsible for educating staff and physicians on accreditation survey process, ISO and regulatory standard related information. Manages and supports a portfolio of strategic projects using the performance improvement mode. Ensures all performance improvement activities are in compliance with regulatory and accreditation bodies.
KEY RESPONSIBILITIES:
1. Primarily leads improvement teams in clinical and operational activities to drive performance excellence and ensure compliance for accreditation readiness action plans, Internal Audit findings, DNV non-conformities and ISO Certification as directed and is accountable for results.
2. Secondarily may lead improvement teams in clinical and operational activities to drive performance excellence for Leap Frog, Q-HIP, PSIs and other initiatives as directed and is accountable for results.
3. Manages continuous survey readiness for assigned Piedmont entities accredited by DNV.
4. Monitors and analyzes data, identifies trends and risk related issues and reports recommendations.
5. Provides staff and physician interventions as appropriate, incorporating process improvement tools.
6. Coordinates staff and physician education related to regulatory standards and survey readiness.
7. Provides guidance for the implementation of Evidence Based Medicine in quality initiatives and/or throughout the pathway program.
8. Assists with special projects.
9. Handoff improvements to operations as standard work and monitors spread across the system.
KNOWLEDGE, SKILLS, ABILITIES
Current knowledge of ISO/DNV accreditation standards, High Reliability principles, patient safety and performance improvement principles
Strong written and verbal communication skills, leadership, facilitation, and time management skills.
Ability to work independently with minimal supervision, as well as, in a collaborative, team environment.
Ability to handle multiple priorities and deadlines.
Skill and ability in Microsoft Office applications.
Ability to manage committees, staffing responsibilities and individual team projects.
Current knowledge of accreditation, ISO and other pertinent regulatory standards.
Training or background in computer, data management, and statistics.
Qualifications:
MINIMUM EDUCATION REQUIRED:
Bachelors Degree or graduate from a recognized accredited school of nursing.
MINIMUM EXPERIENCE REQUIRED:
Five years previous hospital experience in healthcare, information management or quality services. Previous leadership experience required. Experience in healthcare accreditation required.
MINIMUM LICENSURE/CERTIFICATION REQUIRED BY LAW:
None
ADDITIONAL QUALIFICATIONS:
Current RN license preferred
ADDITIONAL PREFERRED QUALIFICATIONS:
Experience with accreditation and regulatory agency requirements (CMS. DHR, OSHA etc.)
Healthcare Quality Certification (CPHQ) and/or ISO 9001 experience preferred
Lean, QPI preferred
This position supports both Piedmont Rockdale and Piedmont Walton
JOB PURPOSE:
Responsible for leading and driving safety and quality performance improvement initiatives and action plans primarily related to hospital accreditation and ISO certification as identified by the internal audit process, accreditation survey results and /or determined by Quality, Safety and Service (QSS) Committee. Manages continuous survey readiness for assigned Piedmont entities accredited by DNV. Promotes a culture of continuous improvement through use of Lean methodology, coaching, tools, data analysis, reliability, sustainability and spread. Responsible for educating staff and physicians on accreditation survey process, ISO and regulatory standard related information. Manages and supports a portfolio of strategic projects using the performance improvement mode. Ensures all performance improvement activities are in compliance with regulatory and accreditation bodies.
KEY RESPONSIBILITIES:
1. Primarily leads improvement teams in clinical and operational activities to drive performance excellence and ensure compliance for accreditation readiness action plans, Internal Audit findings, DNV non-conformities and ISO Certification as directed and is accountable for results.
2. Secondarily may lead improvement teams in clinical and operational activities to drive performance excellence for Leap Frog, Q-HIP, PSIs and other initiatives as directed and is accountable for results.
3. Manages continuous survey readiness for assigned Piedmont entities accredited by DNV.
4. Monitors and analyzes data, identifies trends and risk related issues and reports recommendations.
5. Provides staff and physician interventions as appropriate, incorporating process improvement tools.
6. Coordinates staff and physician education related to regulatory standards and survey readiness.
7. Provides guidance for the implementation of Evidence Based Medicine in quality initiatives and/or throughout the pathway program.
8. Assists with special projects.
9. Handoff improvements to operations as standard work and monitors spread across the system.
KNOWLEDGE, SKILLS, ABILITIES
Current knowledge of ISO/DNV accreditation standards, High Reliability principles, patient safety and performance improvement principles
Strong written and verbal communication skills, leadership, facilitation, and time management skills.
Ability to work independently with minimal supervision, as well as, in a collaborative, team environment.
Ability to handle multiple priorities and deadlines.
Skill and ability in Microsoft Office applications.
Ability to manage committees, staffing responsibilities and individual team projects.
Current knowledge of accreditation, ISO and other pertinent regulatory standards.
Training or background in computer, data management, and statistics.
Qualifications:
MINIMUM EDUCATION REQUIRED:
Bachelors Degree or graduate from a recognized accredited school of nursing.
MINIMUM EXPERIENCE REQUIRED:
Five years previous hospital experience in healthcare, information management or quality services. Previous leadership experience required. Experience in healthcare accreditation required.
MINIMUM LICENSURE/CERTIFICATION REQUIRED BY LAW:
None
ADDITIONAL QUALIFICATIONS:
Current RN license preferred
ADDITIONAL PREFERRED QUALIFICATIONS:
Experience with accreditation and regulatory agency requirements (CMS. DHR, OSHA etc.)
Healthcare Quality Certification (CPHQ) and/or ISO 9001 experience preferred
Lean, QPI preferred