What are the responsibilities and job description for the Dir-Sys Accreditation position at King's Daughters?
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JOB SUMMARY
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Directs accreditation and regulatory affairs initiatives for King's Daughters Medical Center Ashland and Ohio. Serves as the expert resource on regulatory/accreditation and licensure standards and expectations for compliance. Services as the healthcare system's liaison with the Joint Commission (TJC), State Department of Health, CMS, and other regulatory agencies focused on clinical care and safety. Designs and implements a systematic approach to ensure the healthcare system's awareness of accrediting agency requirements throughout the system. Guides the development of policies and procedures as they are related to compliance with regulatory and accreditation guidelines.
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DUTIES AND ESSENTIAL FUNCTIONS
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- Provides overall direction necessary to ensure clinical services are provided in accordance with standards established through state and federal regulations and TJC accreditation standards.
- Provides administrative direction and support though collaboration with leadership and team members for activities related to accreditation and regulatory affairs, TJC certification, patient safety and performance improvement.
- Provides leadership for Medical Center preparation and readiness for regulatory and accreditation surveys: implement a periodic organizational needs assessment for regulatory compliance including intracycle monitoring as required by TJC.
- Identify areas of vulnerability an assist area leaders in developing corrective action plans.
- Identify and communicate areas of success:celebrate and encourage promotion of best practices. Review, assess, and work to revise relavant medical center policies and procedures to ensure compliance with regulatory, accreidtation and professional standards. Recommend and/or devleop new policies to ensure compliance with regulatory, accreditation and professional standards.
- Serve as the healthcare system's liaison with TJC.
- Serve as an expert resource on accreditation and regulatory issues to clinic staff and physicians.
- Determine fiscal requirements and prepares budgetary recommendations; monitors, verifies and reconciles expenditure of budgeted funds.
- Analyzes clinics medical specialties, Home Health, KDMC and KDOH policy throughout the healthcare system for internal consistency and compliance; ensures optimal clinical compliance with accreditation standards.
- Communicates requirements and standards in a timely manner to healthcare system's leadership.
- Translate standards, requirements and p olicies into terms of processes meaningful to the target unit, department, or facility.
- Driect formulaiton of responses to accreditation findings and inquiries.
- Provide consultation to relevant task forces, quality action teams and committees to insure ongoing compliance with standards.
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EDUCATION/LICENSE/CERTIFICATION/OTHER REQUIREMENTS
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Minimum requirement:
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- Bachelor’s Degree in Nursing
- Five years of experience in clinical nursing with increasing role responsibilities.
- Two years of supervisory experience.
- Maintains active Kentucky and Ohio licensure as a Registered Nurse.
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Preferred qualifications:
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- Master’s Degree in Nursing.
- Certified Professional in Healthcare Quality (CPHQ) certification.
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WORKING ENVIRONMENT
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This job operates in a professional office environment routinely using standard office equipment such as computers.
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Occasionally requires travel to and from off-site locations
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The noise level in this position is usually low.
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PHYSICAL DEMANDS
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Frequently required to maintain a stationary position behind a computer or while presenting to individuals or groups.
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Frequently required to move about throughout the Medical Center or while rounding.
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Constantly required to communicate with people electronically, telephonically and in-person requiring talking and hearing.
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Constantly required to operate a computer and telephone.
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Constantly required to lift and/or move up to 15 pounds.
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Frequently required to lift and/or move up to 25 pounds.
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Occasionally required to lift and/or move up to 50 pounds.
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Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, and depth perception.
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