Position Summary + Supports and promotes continuous compliance with Joint Commission and other regulatory standards. + Is familiar with regulatory/ accreditation requirements. Is familiar with CMS and other reporting requirements. + Adheres to established network policies and procedures related to job function. + Adheres to hospital confidentiality statement. Maintains confidentiality of all phases of the performance improvement process related to patients, physicians, staff, and visitors. + Adheres to safety standards within the network and performance improvement service. EDUCATION, TRAINING, EXPERIENCE, CERTIFICATION AND LICENSURE: + Bachelor’s Degree in Healthcare field required, + Masters preferred. + Minimum of 5 years’ experience in healthcare field. SPECIAL EQUIPMENT, SKILLS, OR OTHER REQUIREMENTS: Strong written and oral communication skills, strong interpersonal, motivational and conflict resolution skills. Strong management and administrative skills. Broad-based knowledge of hospital related regulatory compliance requirements. Presentation skills, team player, ability to influence change without direct authority, and negotiation skills. PHYSICAL REQUIREMENTS: + Should be able to push/pull, lift/move 20 lb., be able to perform moderately difficult manual manipulations such as using a keyboard, writing, and filing for extended periods of time, must be able to perform tasks which require hand-eye coordination such as data entry, typing and using photo copiers. Mobility requirements may include the ability to be stationary at a workstation for a prolonged period time in addition to being able to squat or be mobile for a reasonable length of time and distance. Communication requirements include the ability to comprehend the spoken English language in addition to being able to communicate and read the English language. PRIMARY RESPONSIBILITIES OF THE POSITION: + + Supports accreditation activities through rounding, collecting data, and analyzing trends. + Works with departmental leaders on accreditation compliance activities. + Chairs Policy Committee and is responsible to ensure all policies are reviewed timely. + Serves as a contact for the Joint Commission on all communications. + Completion of annual application + Receive and process all invoices. + Maintain access to TJC site. + Reviews all communication from TJC and distributes to appropriate departments. + Chairs Accreditation Readiness Team meetings + Monitors TJC site for changes in standards. + Communicates changes in standards to appropriate departments. + Educates staff on changes in regulatory standards as needed. + Ensures any regulatory changes are reflected in policy as needed. + Coordinates mock survey activities. + Coordinates all onsite regulatory surveys. + Initiate communication of surveyor arrival and establish a location for survey activities. + Work with survey team to establish a schedule for survey activities. + Coordinates Ellis team members to serve as guides and scribes. + Maintains binder will all required “first hour” documents. + Works with department leaders to develop plans of correction for survey findings. + Ensures all audits to measure sustained change are completed timely. + Attends departmental meetings/huddles to educate staff on Joint Commission standards and activities. + Coordinates Good Catch Program + Serves as a back up to the Data Quality Manger + Running reports + Producing data to departments as requested + Oversees Stroke Program Coordinator to ensure all NYS and TCJ requirements are met + Monitor critical key performance indicators, such as Value Based Purchasing (VBP), Hospital Acquired Conditions (HAC) and initiates ongoing performance improvement opportunities with stakeholders to drive improvement actions. + Educates all staff on VBP, HAC, PFP and all other performance measure indicators as appropriate. + Perform quality assurance functions as they relate to reporting and data validation. + Ensures submission of core measure and registry data. + Directs the review and evaluation of clinical practice at the request of regulatory agencies. + Reviews and responds to Third Party Payor complaints. + Oversee ad-hoc and operational reports. + Participates in various committees including DEI, Emergency Preparedness, Infection Control/Antibiotic Stewardship, EOC/Safety. + Participates in all hospital emergency drills. + Prepares data for and participates in PSI/Mortality committee. + Oversees and ensures completion of OPPE/FPPE. + Participates in other committees as needed. + Assists with completion of Leapfrog survey. + Responsible for Joint Commission ORYX measure submissions + Other duties as assigned to meet the needs of the organization Ellis Medicine is committed to creating a diverse environment and is proud to be an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, creed, color, religion, sex/gender, age, national origin, disability, genetic information, predisposition or carrier status, military or veteran status, prior arrest, or conviction record, marital or familial status, sexual orientation, transgender status, gender identity, gender expression, reproductive health decisions, or domestic violence victim status. Salary Range: $31.50-47.26/hour Pay is based on experience, skills, and education. Exempt positions under the Fair Labor Standards Act (FLSA) will be paid within the base salary equivalent of the stated hourly rates. The pay range may also vary within the stated range based on location.