Description

Job Summary

Provides compliance for Baylor, Scott and White Health accreditation efforts. Reviews include facilitation of continuous survey readiness. Serves as an internal consultant for interpreting standards and assessing functional compliance. Participates in survey-related activities. Supports and sustains hospital-wide continuous improvement efforts.

Essential Functions of the Role

• Coordinates Joint Commission activities to ensure facilities comply with all required standards. Develops a consistent plan for continuous compliance with accreditation standards.

• Reviews and recommends changes, additions, or deletions of policies and procedures. Evaluates health care improvement, patient safety, and information management plans. Assesses environment of care management and other organization plans.

• Provides consultative help for action plan development. Tracks progress and coordinates activities to assess compliance with accreditation standards. Identifies gaps and opportunities for improvement. Reports compliance status to senior leadership.

• Prepares written responses and development of corrective action plans regarding Joint Commission recommendations.

• Provides education and training on accreditation requirements and serves as an internal consultant facilitating quality improvement teams.

• Coordinates preparation for and execution of accreditation surveys including follow-up and ongoing deliverables.

• Serves as facility liaison to surveyors from the Texas Department of State Health Services (TDSHS) during complaint investigations or

• Medicare surveys. Serves as facility coordination point for all hospital licensure requirements and activities set by TDSHS.

• Presents periodic reports to senior leadership, medical staff departments, and the board of trustees about changes in accreditation standards, COP, or licensure rules.

Key Success Factors

• Knowledge of strategic planning, assessment initiatives, and accreditation standards.

• Verbal and written communication skills.

• Statistical and presentation skills.

• Skill in the use of computers and related software applications.

• Ability to assess compliance with accreditation standards and develop corrective action plans.

• Ability to work effectively with a wide range of constituencies.

• Ability to collect and organize data.

• Ability to prepare accurate reports on program status and progress.

Preferred Experience

• Clinical Background

• Experience with MS Office Suite

• Epic Experience

Minimum Qualifications

• EDUCATION - Bachelor's Degree

• EXPERIENCE - 3 Years of Experience