Industry: Hospitals & Medical Centers•
5 - 7 years
Posted 76 days ago
Responsible for the system support of quality management systems. Collaborates with multi-disciplinary teams, major system departments and leadership to create efficient, reliable and cost effective processes which support the provision of patient care. Performs analytical and project management to support the regulatory/accreditation and patient safety processes to assess measure and report ongoing compliance with regulatory standards and evidence-based safety practices. The position Works collaboratively with the corporate and hospital departments that have direct or related responsibility for these Functions.
Collaborates with major stakeholders at the system and hospital level to create efficient, reliable and cost effective processes which support the provision of patient care.
Establishes and Maintains a standardized and ongoing program for regulatory readiness that promotes continual improvement in compliance related to CMS Conditions of Participation, State Hospital Licensing Rules and accreditation programs for CMS deemed status
Establishes and Supports system governance structure and provide oversight of system and hospital policy and procedures to meet changing regulatory and accreditation needs
Collaborates with stakeholders in the patient safety program, medical staff quality and other areas , Coordinates related Functions
Establish and standardize processes for hospital survey readiness including a) preparation; b) audits, tools and evaluation of compliance, i.e., audit/survey programs, database of standards evidence/scoring
Supports hospital level leadership in hospital regulatory and accreditation surveys
Develops program and revisions to meet system needs