Position Summary: 

The System Manager of Accreditation, Quality Management and Infection Prevention is responsible for assisting with planning, directing, organizing, monitoring system certification and accreditation programs subject to policies, budgets, objectives and directives mandated by regulatory agencies, certifying or accrediting body and the hospital administrative team. Provides system-wide direction and support for maintaining all accreditation and certification standards to achieve upholding a highly reliable culture in patient care delivery through an integrated quality management system using continuous improvement and internal auditing programs. Collaborates with cross-functional stakeholders and leaders in process-redesign to decrease variation and improve conformance to standards and generate excellence in care delivery. Partners with executive leaders, administrators, physicians, nursing departments and other staff for ensuring that the requirements of the Quality Management System (QMS) are implemented and maintained to include metric monitoring and analysis, detecting risk, prioritizing risk, and facilitating council/taskforce output. Develops and maintains expert knowledge of accreditation and certification standards and CMS CoPs. Communicates changes in standards effectively and orderly. Upholds and supports a functioning quality reporting structure to create a platform for communicating all quality reporting structure activities to all levels of the organization to include the highest governing authority. Facilitates all internal and external survey activities; this will include Corrective Action Plan submissions to accrediting and certifying bodies. Manages performance of and provides oversight of job duties for clinical quality specialist, administrative assistant, and continuous improvement specialist to successfully carry out a cohesive cultural, educational, and communication plan to achieve desired strategic priorities and goals.

Minimum Qualifications:

Required

Bachelor’s degree in NursingMontana Licensure (Registered Nurse)American Heart Association BLS

Preferred

Master’s degree in Healthcare related field

Essential Job Functions:

In addition to the essential functions of the job listed below, employees must have on-time completion of all required education as assigned per DNV requirements, Bozeman Health policy, and other registry requirements.

Assists Director with broad operations to ensure the provision of comprehensive departmental services in compliance with all regulatory agencies and healthcare system requirements.Ensures a collaborative departmental approach to long-range strategic operational planning, care and service design and development of organizational policies, which reflect the mission of the organization.Continuously assesses, measures and improves departmental performance.Demonstrates responsible management of all departmental resources.Demonstrates clinical/technical and managerial competency. Ensures staff professional needs are met.Leads, teaches, inspires, helps and consistently demonstrates healthcare system behavioral standards.

Knowledge, Skills, and Abilities

Strong leadership managerial skills; ability to plan, delegate, monitor and improve work performanceDemonstrates sound judgement, patience, and maintains a professional demeanor at all timesAbility to work in a busy and stressful environmentStrong interpersonal, verbal and written communication skillsCreativity, problem analysis and decision makingExercises tact, discretion, sensitivity and maintains confidentialityDetail oriented, organizational skills and the ability to prioritizeStandard office equipment and computer applications; MS Office, EMR, internet applications etc.Ability to work varied shifts

Physical Requirements

Lifting, Pushing, and Pulling: Support 50 pounds of weight (patient, assist with bedside needs, etc.) Lift 50 pounds (pick up a child, transfer a patient, etc.) Carry equipment/supplies. Use upper body strength (CPR, physically restrain patient, etc.)Extended Hours: The role may involve working for extended periods, requiring sitting, walking, or standing for eight or more hours daily.Flexible Schedule: The position may necessitate working beyond a standard 40-hour workweek, including weekends and after-hours shifts.On-Call Availability: On-call work may be required to respond to organizational and patient needs promptly.Effective Communication: Proficient in effective communication, both in person and through various technologies.Handling Challenging Situations: The role may involve dealing with upset individuals, requiring the ability to de-escalate situations and work effectively with frustrated patients or families.Repetitive Tasks: Ability to perform repetitive tasks as needed to fulfill job responsibilities.           

Exposures

Tasks Include Potential Exposure: Job tasks may involve exposure to:

Bloodborne pathogens, such as blood, bodily fluids, or tissues.Radiation in settings where medical imaging procedures are performedVarious chemicals and medications used in healthcare settings. Job tasks may involve handling pharmaceuticals, disinfectants, and other substances.Infectious diseases due to contact with patients who may have contagious illnesses.Emotionally challenging situations, such as dealing with distressed patients or difficult family interactions.

The above statements are intended to describe the general nature and level of work being performed by people assigned to the job classification.  They are not to be construed as a contract of any type nor an exhaustive list of all job duties performed by the personnel so classified.

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