JOB SUMMARY

PROVIDES COMPLIANCE FOR BAYLOR, SCOTT AND WHITE HEALTH ACCREDITATION EFFORTS AND REVIEWS TO INCLUDE FACILITATION, OF CONTINUOUS SURVEY READINESS. SERVES AS AN INTERNAL CONSULTANT FOR THE INTERPRETATION OF STANDARDS AND FUNCTIONAL COMPLIANCE ASSESSMENT AND PARTICIPATES IN SURVEY RELATED ACTIVITY. SUPPORT AND SUSTAIN HOSPITAL-WIDE CONTINUOUS IMPROVEMENT EFFORTS.

ESSENTIAL FUNCTIONS OF THE ROLE

• COORDINATES JOINT COMMISSION ACTIVITIES TO ENSURE ASSIGNED FACILITIES ARE IN COMPLIANCE WITH ALL REQUIRED STANDARDS AND HAVE AN INTEGRATED, CONSISTENT PLAN FOR MAINTAINING CONTINUOUS COMPLIANCE WITH ALL REQUIRED ACCREDITATION STANDARDS.

• REVIEWS AND RECOMMENDS CHANGES, ADDITIONS OR DELETIONS OF POLICIES AND/OR PROCEDURES, HEALTH CARE IMPROVEMENT PLAN, PATIENT SAFETY PLAN, MANAGEMENT OF INFORMATION PLAN, ENVIRONMENT OF CARE MANAGEMENT PLANS, AND OTHER ORGANIZATION PLANS.

• PROVIDES CONSULTATIVE ASSISTANCE FOR DEVELOPMENT OF ACTION PLANS, TRACKS PROGRESS AND COORDINATES ACTIVITIES TO ASSESS COMPLIANCE WITH ACCREDITATION STANDARDS. IDENTIFIES GAPS AND OPPORTUNITIES FOR IMPROVEMENT. REPORTS TO SENIOR LEADERSHIP THE STATUS OF COMPLIANCE WITH STANDARDS.

• 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(S) LICENSURE REQUIREMENTS AND ACTIVITIES AS SET FORTH BY TDSHS.

• PRESENTS PERIODIC REPORTS TO SENIOR LEADERSHIP, MEDICAL STAFF DEPARTMENTS AND THE BOARD OF TRUSTEES REGARDING 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.

BENEFITS

Our competitive benefits package includes the following

• Immediate eligibility for health and welfare benefits

• 401(k) savings plan with dollar-for-dollar match up to 5%

• Tuition Reimbursement

• PTO accrual beginning Day 1

Note: Benefits may vary based upon position type and/or level

QUALIFICATIONS

• EDUCATION - Bachelor's

• EXPERIENCE - 3 Years of Experience

As a health care system committed to improving the health of those we serve, we are asking our employees to model the same behaviours that we promote to our patients. As of January 1, 2012, Baylor Scott & White Health no longer hires individuals who use nicotine products. We are an equal opportunity employer committed to ensuring a diverse workforce. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability status, protected veteran status, or any other characteristic protected by law.