Accreditation and Patient Safety Coordinator

Risk Management/QRM

8am-430pm; Full Time

Standard Hours/Week:

General Description:
Under the general supervision of the Quality Manager, the Accreditation and Patient Safety Coordinator coordinates the ongoing development of a continuous performance improvement culture that includes the coordination of all functions related to accreditation, surveys, and disease-specific certification processes. Serves as the liaison for external accreditation agencies. Serves in an advisory capacity to the medical staff, hospital departments, clinics, medical offices, committees and Performance Improvement/Patient Safety Committees. Is familiar and acts as a resource for other teams in applying and using Quality Improvement/Performance Improvement/Process Improvement methodology and statistical tools. Is knowledgeable regarding core measures, appropriate care measures, and pay for performance measures. Has a working knowledge about data reports and analysis to promote improvement.

Key Responsibilities
  • Acts as accreditation agency/organization liaison, coordinates accreditation preparation work teams, and assists with the continued compliance with standards to attain accreditation with high scores. This includes the Joint Commission, the Disease Specialty Certification Programs, Leapfrog, and other regulatory agencies
  • Provides assistance in monitoring compliance with standards and regulations, providing a summary of trended performance improvement data to hospital/clinic committees, medical staff committees, and the Board of Directors.
  • Actively participates and supports the Patient Safety initiatives ensuring compliance with the requirements. Works with staff to develop and implement corrective action plans to ensure ongoing compliance. Monitors for effectiveness implemented corrective action plans and works with staff to modify where applicable
  • Performs hospital, clinic, and medical office environmental rounds on an ongoing basis to monitor for compliance and to use it as an opportunity to educate staff.
  • Assists and leads managers, directors and medical staff committees with problem identification, analysis, and implementation of process change. Establishes and maintains files of performance improvement activities as they relate to the accreditation process.
  • Provides ongoing Performance Improvement education, accreditation and disease-specific standards education, regulatory agency requirements for staff; provides just in time training as identified and needed.
  • Utilizes and supports other areas with performance improvement tools and methodologies. Develops meaningful evaluation methodologies and effectively articulates them. Aids in the initiation of performance improvement/quality improvement/process improvement teams and serves as mediator or facilitator and project team member as they relate to the accreditation process.
  • Ensures data security and confidentiality. Knows fire, disaster, and safety procedures and regulations as pertains to the work area.
  • Performs similar or related duties as assigned.
  • Knows fire, disaster and safety procedures and regulations as it pertains to the work area.

Formal Education:
  • Associate's Degree in nursing required. Bachelor's Degree or Master's Degree in nursing strongly preferred.

Work experience:
  • Three to Five years in healthcare; one-year minimum experience in hospitals working with Quality and Performance Improvement initiatives; accreditation agency experience or experience with accreditation agency surveys considered a plus; one-year management experience preferred.

Required Licenses, Certifications, Registrations:
  • Current State of Florida RN Licensure required. CPHQ, CJCP, or comparable credentialing strongly preferred.
  • Lean Six Sigma Green Belt preferred.

Full Time Benefits:
Eligible to participate in a number 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
  • EAP, Flex Spending, Accident, Critical and Other Applicable Benefits

Parrish Healthcare is a caring community of healthcare professionals passionate about excellence and fulfilling our mission of providing Healing Experiences For Everyone All The Time®.

Parrish Healthcare has a Culture of Choice®. This means a we have a healing work environment that empowers people to aspire to be their very best. We partner passionate, talented and skilled people in the right role with the right resources. We provide a clear and strategic direction to achieve superior results on behalf of the communities we serve.