Mgr, Accreditation

Description:
JOB PURPOSE:
Responsible for leading and driving safety and quality performance improvement initiatives and action
plans primarily related to hospital accreditation and ISO certification as identified by the internal audit
process, accreditation survey results and /or determined by Quality, Safety and Service (QSS)
Committee. Manages continuous survey readiness for assigned Piedmont entities accredited by DNV.
Promotes a culture of continuous improvement through use of Lean methodology, coaching, tools, data
analysis, reliability, sustainability and spread. Responsible for educating staff and physicians on
accreditation survey process, ISO and regulatory standard related information. Manages and supports a
portfolio of strategic projects using the performance improvement mode. Ensures all performance
improvement activities are in compliance with regulatory and accreditation bodies.
Qualifications:
MINIMUM EDUCATION REQUIRED:
Bachelors Degree or graduate from a recognized accredited school of nursing.
MINIMUM EXPERIENCE REQUIRED:
Five years previous hospital experience in healthcare, information management or quality services.
Previous leadership experience required. Experience in healthcare accreditation required.
MINIMUM LICENSURE/CERTIFICATION REQUIRED BY LAW:
None
ADDITIONAL QUALIFICATIONS:
Current RN license preferred
ADDITIONAL PREFERRED QUALIFICATIONS:
Experience with accreditation and regulatory agency requirements (CMS. DHR, OSHA etc.)
Healthcare Quality Certification (CPHQ) and/or ISO 9001 experience preferred
Lean, QPI preferred