Patient Safety and Accreditation Specialist
1 week ago
Department: Risk Management/QRM
Schedule: 8am-4:30pm; Full Time
Standard Hours/Week: 40
Role Summary:
Under the guidance of the Quality Manager, the Patient Safety and Accreditation Specialist is responsible for fostering a culture of continuous performance enhancement. This role encompasses the management of all activities related to accreditation, surveys, and certification processes specific to diseases. The specialist acts as a key liaison for external accreditation bodies and provides advisory support to medical staff, various hospital departments, clinics, and committees focused on Performance Improvement and Patient Safety. The role requires a strong understanding of Quality Improvement methodologies and statistical analysis to drive improvement initiatives.
Key Responsibilities:
- Serve as the primary liaison for accreditation organizations, coordinating preparation teams and ensuring compliance with standards to achieve high accreditation scores, including those from the Joint Commission and other regulatory entities.
- Assist in monitoring adherence to standards and regulations, providing summarized performance improvement data to relevant committees and the Board of Directors.
- Engage actively in Patient Safety initiatives, ensuring compliance with established requirements and collaborating with staff to develop and implement corrective action plans.
- Conduct regular environmental assessments in hospitals, clinics, and medical offices to ensure compliance and provide educational opportunities for staff.
- Support managers and committees in identifying problems, analyzing processes, and implementing necessary changes, while maintaining records of performance improvement activities related to accreditation.
- Deliver ongoing education on Performance Improvement, accreditation standards, and regulatory requirements, including just-in-time training as needed.
- Utilize performance improvement tools and methodologies to develop effective evaluation strategies, facilitating teams focused on quality enhancement as they relate to accreditation.
- Ensure data security and confidentiality, while being knowledgeable about safety procedures and regulations relevant to the work environment.
- Perform related duties as assigned.
Education Requirements:
- Associate's Degree in Nursing required; Bachelor's or Master's Degree in Nursing preferred.
Experience Requirements:
- Three to five years in healthcare, with at least one year of experience in hospitals focusing on Quality and Performance Improvement initiatives; experience with accreditation agencies is a plus; one year of management experience preferred.
Licenses and Certifications:
- Current State of Florida RN Licensure required; CPHQ, CJCP, or similar credentials preferred.
- Lean Six Sigma Green Belt certification preferred.
Benefits:
Eligible for a variety of PMC-sponsored benefits, including:
- Annual accrual of 152 Personal Leave Bank (PLB) hours
- Health, Dental, and Vision Insurance
- 403(b) Retirement Program
- Tuition Reimbursement/Educational Assistance
- Employee Assistance Program, Flexible Spending, and other applicable benefits
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