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Job Summary

Oversees the daily continuous accreditation readiness for assigned facility(s). Coordinates department and facility accreditation compliance meetings, analyzes trends of performance metrics, identifies opportunities for improvement, develops action plans, measures success of these action plans, creates the records and follow-up metrics for each meeting and activity.

Essential Functions

• Leads continuous accreditation readiness efforts and coaches others in the development of accreditation improvement capabilities. Provides direction to department and facility leadership in the planning of a systematic, organization-wide approach to continuous accreditation readiness.

• Maintains expert competence in accreditation standards and communicates relevant changes to appropriate leaders and staff.

• Maintains a close working relationship with facility leadership to optimize the quality and patient safety culture and to support constant state of readiness for accreditation reviews.

• Facilitates assessments, develops, implements and evaluates corrective action plans based on past surveys and preparatory tracer activities. Compiles and distributes compliance reports including appropriate action plans to oversight councils. Supports and guides the facility in continuous survey readiness efforts.

• Participates in the review, analysis and development of plans.

• Prepares reports and presentations.

• Coordinates department and facility accreditation compliance meetings, analyzes trends of performance metrics, identifies opportunities for improvement, develops action plans, measures success of these action plans, creates the records and follow-up metrics for each meeting and activity. Re-assesses approach to maximize success.

• Assists leadership in defining key performance indicators and developing measurement tools to evaluate quality improvements.

• Utilizes facilitation skills (both team and individual), data analysis and statistical process control to effect improvement in quality and clinical outcome.

• Consults with and trains staff to implement monitoring and measurement tools, and data analysis techniques. Provides education and training on accreditation compliance and accreditation matters.

• Collaborates with staff to facilitate improvement teams to achieve facility and System quality and patient safety goals.

• Assists with system and regional quality initiatives.

Physical Requirements

Works in an office environment. Requires walking, standing, long periods of sitting and computer use. Intact sense of sight and hearing required. Travels to facilities as needed. Must have current state driver's license.

Education, Experience and Certifications

Bachelor's Degree required; Master's Degree preferred. RN or other clinical licensure preferred. Certification in healthcare quality, patient safety or related accreditation entity preferred, required within 1 year of employment.

Atrium Health is one of the nation’s leading healthcare organizations, connecting patients with on-demand care, world-class specialists and the region’s largest primary care network. A recognized leader in healthcare delivery, quality and innovation, our foundation rests on providing clinically excellent and compassionate care.

We’ve been serving our community since 1940, when we opened our doors as Charlotte Memorial Hospital. Since then, our network has grown to include more than 40 hospitals and 900 care locations ranging from doctors’ offices to behavioral health centers to nursing homes.

Our focus: Delivering the highest quality patient care, supporting medical research and education, and joining with partners outside our walls to keep our community healthy.