Job Summary

Responsible for accrediting body information and services for CAMC and CAMCHSI. General areas of responsibility include: serves as consultant to administration, medical staff, clinical support services, nursing and support services on interpretation of accrediting body standards including development of strategies to meet the intent of the standards; establishment and maintenance of a comprehensive system to identify, evaluate, and prevent or minimize areas of noncompliance with accrediting body standards; mobilization of resources to address areas of noncompliance and monitor results of actions taken; coordinating of accrediting body functions among administration, medical staff, professional nursing, clinical support services, and other areas of the institution impacted by accrediting body standards; establishment and maintenance of a comprehensive system for communication to all levels of the organization upon unannounced arrival of accrediting body Survey or for hospital and laboratory point-of-care surveys; establishment and leadership responsibility for the accrediting body Command Center during on-site visits; resource to V.P. for Disease Specific Specializations (DSS) from accrediting body. Serve as chairperson of accrediting body Steering Committee and participation and/or facilitation of the accrediting body Core Team and Executive Steering Team in absence of the V.P. Liaison with accrediting body on all matters relating to accreditation.

Responsibilities

• Accountable for coordination of accrediting body activities for CAMC and support coordination for CAMCHSI entities and Partner hospitals. This includes serving as liaison with accrediting body, completion of applications for surveys, coordination of survey schedules, preparation and submission of any written evidence of standards compliance (ESCs)and coordination of any unannounced surveys for ESC confirmation. • Accountable for coordination of unannounced survey process for hospital and laboratory point of care surveys. • Accountable as resource for application and schedule planning for accrediting body Disease Specific Care (DSC) certification. • Serve as consultant on interpretation of accrediting body standards and strategies to meet the intent of the standards. Contact accrediting body when necessary for clarification on intent of standards and whether specific strategies meet the intent of the standards. Information from accrediting body and consultants is communicated to the appropriate personnel. • Serve as Chairperson of accrediting body Steering Committee. Work with committee members and appropriate others to ensure comprehensive medical center wide mechanism to maintain compliance with accrediting body standards. Assist in formulation of corrective action plans and evaluate the effectiveness of these in meeting the intent of the accrediting body standards. Participate and/or facilitate accrediting body Core Team and Executive accrediting body Steering committee in absence of V.P. • Accountable for annual self-assessment of effectiveness of medical center to meet the intent of the accrediting body standards. This assessment is done in collaboration with accrediting body Steering Committee focusing on continual preparation. Submission of periodic performance review (PPR) to accrediting body annually for accrediting body hospital and laboratory point-of-care accreditation. • Collaborate with Director of Nursing Quality and Resource Management, service line vice presidents and corporate directors on medical center quality improvement activities including annual evaluation of QI activities, the performance improvement evaluation process, development of important aspects of care and indicators, and quarterly reporting of QI activities. • Responsible for ongoing management of documents required at time of unannounced hospital and laboratory point-of-care surveys. • Responsible for maintaining awareness of national trends and advancements in areas of responsibility and demonstrating commitment to process of continuous quality improvement. • Design and provide inservice programs for departments on accrediting body standards. • Responsible for coordination of quarterly consulting school and all accrediting body consultant visits. • Provide consultative services and inservices on accrediting body standards, survey process, and continuous quality improvement to CAMCHSI entities and Partners Hospitals. • Responsible for facilitation of organization's response to draft standards that may affect the organization operations. • Maintain understanding of externally mandated program requirements, regulations and standards of state and federal agencies, and accreditation agencies. Shares information with appropriate persons/departments. • Responsible for all communication to accrediting body regarding functional/organizational integration and program or service changes. • Distribute to all departments and administration, accrediting body standards and scoring guidelines. Share information from periodicals relating to accrediting body accreditation agencies. Share information with appropriate persons/departments. • Responsible for all communication to accrediting body regarding reported issues, concerns, or complaints. • Assure necessary information is communicated among departments/services and/or professional disciplines when problems or opportunities to improve processes involve more than one department/service and/or professional discipline. • Serve as a member of Administrative Policy and Procedure Committee. • Accountable for development of annual, departmental and individual goals and objectives. • Develop the Staffing Effectiveness plan. • Schedule, lead and prepare meeting minutes. • Ensure data collection is forwarded in a timely manner to the appropriate individuals for determination of relationships of indicators while requesting an action plan and follow up from managers when such indicators exist. • Provide and annual report to the Board Committee on Quality. • Maintain all records. Ensure up to date information is available on the TJC website for CAMC.

Knowledge, Skills & Abilities

Patient Group Knowledge (Only applies to positions with direct patient contact) The employee must possess/obtain (by the end of the orientation period) and demonstrate the knowledge and skills necessary to provide developmentally appropriate assessment, treatment or care as defined by the department’s identified patient ages. Specifically the employee must be able to demonstrate competency in: 1) ability to obtain and interpret information in terms of patient needs; 2) knowledge of growth and development; and 3) understanding of the range of treatment needed by the patients. Competency Statement Must demonstrate competency through an initial orientation and ongoing competency validation to independently perform tasks and additional duties as specified in the job description and the unit/department specific competency checklist. Common Duties and Responsibilities (Essential duties common to all positions) 1. Maintain and document all applicable required education. 2. Demonstrate positive customer service and co-worker relations. 3. Comply with the company's attendance policy. 4. Participate in the continuous, quality improvement activities of the department and institution. 5. Perform work in a cost effective manner. 6. Perform work in accordance with all departmental pay practices and scheduling policies, including but not limited to, overtime, various shift work, and on-call situations. 7. Perform work in alignment with the overall mission and strategic plan of the organization. 8. Follow organizational and departmental policies and procedures, as applicable. 9. Perform related duties as assigned.

Education 

• Bachelor's Degree (Required) Experience: 5 - 7 Years - Healthcare System

Credentials 

• Registered Nurse (Required)

Work Schedule: Days

Status:  Full Time Regular 1.0

Location: Northgate-400 Association Dr.

Location of Job: US:WV:Charleston

Talent Acquisition Specialist: Anita J. Ferguson anita.ferguson@vandaliahealth.org