at NorthShore University Health System in Arlington Heights, Illinois, United States
Job Description
Job Description:
GENERAL SUMMARY: (A brief 1-2 sentence statement of the reason the job exists.)
Reporting to the Vice President/Chief Quality Officer and in collaboration with the Chief Medical Officer, coordinates and serves as primary contact for accreditation, certification and regulatory activities, including survey preparation and readiness assessments for all facilities within Northwest Community Healthcare accredited by The Joint Commission (TJC), the Accreditation Association for Ambulatory Health Care (AAAHC), Illinois Department of Public Health (IDPH) and the Centers for Medicare and Medicaid Services (CMS). Assures the effective and efficient operation of the Infection Prevention Team and selected strategic performance improvement teams.
REPRESENTATIVE FUNCTIONS:
Coordinates and serves as primary contact for accreditation and regulatory activities, including survey preparation and readiness assessments for all Northwest Community Healthcare facilities accredited by TJC, AAAHC, IDPH and CMS. Assists with interpretation of standards and regulations, and serves as the point of contact for accreditation bodies.
Provides education for the organization regarding regulatory and accreditation issues. Identifies learning needs and opportunities and researches training content and methods in collaboration with key areas impacted.
Facilitates actionable plans for the development, communication, implementation and tracking of action plans necessary to close identified gaps in care or compliance related to the various regulatory bodies in conjunction with departments or internal content experts. Works collaboratively with content area experts in the organization to ensure a continuous state of readiness throughout the organization.
Actively coordinates the organization's tracer program to ensure continuous readiness and integration of new standards or regulations. Assists leadership with the development of continuous readiness plans.
Interviews, hires, disciplines and discharges team members in accordance with NCH policies and procedures. Regularly evaluates the performance of team members in accordance with the hospitals performance management system. Supports development of team member's knowledge and skills through regular feedback, recognition of positive accomplishments and coaching opportunities.
Coordinates responses related to Quality of Care concerns from the Quality Improvement Organizations (QIO) of regulatory bodies and insurers across the NCH system.
Responsible for monitoring regulatory websites for new information and new or revised standards, collaboratively evaluating compliance towards those changes and is instrumental in the development, assessment and achievement of organization readiness.
Responsible to evaluate the organization's compliance with Sentinel Event Alerts, and to document and communicate appropriate recommendations for improvement in partnership with Risk Management and the Patient Safety Officer.
Responsible for tracking, reporting, and ensuring the completion of action items resulting from Ad Hoc investigations related to accreditation and/or compliance.
Oversees coordination of any responses to the Joint Commission related to Evidence of Standards Completion (ESC) or other post survey activity. Act as the point of contact for Quality of Care complaints and is responsible for coordinating the response, including any action items resulting from the investigation.
Maintains an inventory of accreditation and licensure activity, including but not limited to, correspondence, calendar, signatures, project plans, etc.
Completes the Intracycle Monitoring Focused Standards Assessment (ICM FSA) to meet the necessary requirements of the Joint Commission.
In collaboration with the VP Chief Quality Officer and the Medical Director of the Infection Prevention Committee, provides oversight and supervision of the Infection Prevention staff, their job responsibilities, functions and goals working to enhance the standardization of infection prevention practices across the organization. Continuously develops the skills and abilities of the Infection Prevention team.
Adheres to all Northwest Community Hospital standards, policies, and procedures.
SPECIAL SKILLS AND ABILITIES REQUIRED:
High level of interpersonal and communication skills to interact effectively with all levels of NCH staff, leadership, physicians, and outside agencies.
High level of organizational skills necessary to complete complex detailed, accurate and timely projects and assignments. Must be able to juggle multiple requests while meeting report or project deadlines.
Ability to work independently and proactively with a high degree of accuracy.
Analytical skills necessary to determine the... For full info follow application link.
EOE: Race/Color/Sex/Sexual Orientation/ Gender Identity/Religion/National Origin/Disability/Vets, VEVRRA Federal Contractor.
