Responsible for coordinating ongoing activities to support organizational continual readiness for accreditation and other Centers for Medicare & Medicaid Services (CMS) and state licensure surveys. Acts as point of contact for accreditation related issues. Provides guidance and assists departments to ensure adherence to regulatory requirements.


Principal Accountabilities:

1. Establishes and implements systems and processes to ensure continuous adherence to regulatory standards within the assigned medical center. 
2. Leads and coordinates all Joint Commission Medical Center Accreditation surveys.
3. Identifies improvement opportunities and provides support and/or consultative services to quality improvement teams. 
4. Collaborates with legal and risk management teams to track and trend adverse events, conducts root cause analysis (RCAs) reviews, and ensures the development and timely execution of risk mitigation strategies.
5. Participates in the development and implementation of policies, programs, and initiatives in order to improve the overall quality of patient cares services.
6. Performs other related duties as assigned.