Manager, Health System Accreditation and Patient Safety Services
Southeast Georgia Health System
Location: Brunswick, Georgia
Type: Full Time
Required Education: 4 Year Degree
Hospital, Public and Private
Internal Number: -
Southeast Georgia Health System
CARE MEANS MORE.
"Care" is not merely a word at Southeast Georgia Health System. It's our promise to our team members, our patients and families, and ourselves—to be the finest professionals possible. As the region's health care provider and employer of choice, we offer outstanding opportunities, rewarding experiences, and a great quality of life. Join our team, learn what we stand for, and discover how much more you can enjoy your career.
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Manager, Health System Accreditation and Patient Safety Services
Southeast Georgia Health System Brunswick, GA
Southeast Georgia Health System has an opportunity for a Manager, Health System Accreditation and Patient Safety Services
Make the most of your specialized credentials to manage the accreditation and certification process for the Health System. We seek a detail-oriented leader to facilitate the compliance with the Joint Commission (TJC) standards for hospital accreditation, to obtain full accreditation for both the Brunswick and Camden campuses. In this key role also will assist and facilitate other accreditation/certifications being sought by the Health System.
Summary: Responsible for management of the Accreditation/Certification processes for the Health System. Facilitates compliance with The Joint Commission ("TJC") Standards for Hospital Accreditation, with the goal of obtaining full accreditation for both the Brunswick and Camden campuses. Serves in the role of Site Survey Coordinator for TJC surveys and performs a supportive role in other health system regulatory and accreditation surveys, facilitating where needed. Responsible for oversight of the health system's patient safety services, providing information and awareness of current evidence based patient safety practices to leaders. All team members of Southeast Georgia Health System will promote a culture of safety, follow established policies, and adhere to all state and federal regulatory requirements, TJC requirements, and national patient safety standards.
Service Excellence: All team members of Southeast Georgia Health System will promote service excellence by developing and maintaining positive relationships with customers, other team members, and the medical staff and will ensure the highest quality of care by performing their responsibilities according to the highest professional standards.
Manages and directs implementation of TJC's Hospital Accreditation Standards Manual, and chairs the monthly Continuous Survey Readiness ("CSR") Committee meetings for the two (2) hospitals on the Brunswick and Camden Campuses.
Directs the planning, development, implementation, and refinement of the Health System's CSR program, with the goal of maintaining full TJC Accreditation for both hospitals.
Ensures the accuracy and timeliness of responses from the CSR Functional Chapter Chairpersons on required submissions (i.e., General Application, annual Periodic Performance Reviews,
Evidence of Standards Compliance, Measures of Success, Sentinel Event response) to TJC and the Center for Medicare & Medicaid Services ("CMS").
Provides oversight and guidance for all accreditation programs, i.e., CMS annual long term care facility surveys of our two (2) Senior Care Centers; Occupational Safety & Health Administration ("OSHA") complaint surveys.
Internal Communication Activities:
Manages Health System compliance with TJC and other regulatory and accrediting organizations, including CMS and the Georgia Department of Community Health.
Provides direction to the TJC Chapter Chairpersons on ongoing Joint Commission activities Reports quarterly to the Compliance Committee of the SGHS, Inc. Board, and monthly at the Quality and Patient Safety Operations Council (QAPSOC) and Leadership meetings as needed, about the status of the Health System's continual survey readiness.
Provides ad hoc reports to Administration and the Medical Staff on both campuses, as needed. Directs and collaborates with Leadership Team and Medical Staff in the implementation of TJC Standards & National Patient Safety Goals.
Serves on Health System and hospital committees including, but not limited to, QAPSOC, the EOC/Safety Committee, Pharmacy & Therapeutics, and other pertinent committees for both the Camden and Brunswick campuses.
Participates in environmental rounds and emergency preparedness activities.
External Liaison with National / State Accreditation Organizations:
Cultivates and manages Health System relationships with accreditation organizations.
Attends state and national TJC meetings, and represents the Health System at state meetings.
Responsible for overall relationship with designated the System's Joint Commission Resources representative, including arranging periodic JCR site visits and mock surveys.
Facilitates corrective action and responses to mock survey findings. Manages unannounced complaint survey visits or cases for all departments/entities in the Health System (i.e., nursing homes and Southeast Georgia Physician Associates (SGPA), Inc.) from regulatory and accrediting agencies.
Health System Policies & Procedures Management:
Has direct oversight of the Health System's electronic policy system, Policy Tech, to ensure compliance with TJC, Medicare Conditions of Participation, and other Federal, State, and local regulations.
Develops model templates, work flow tools, and leads work groups to create or revise policies and procedures. Works with the Information Systems Department on periodic Policy Tech updates and interfaces with the Health System to assure proper operation of the online program.
Responsible for oversight of the Health System's Emergency Access Package for monthly Policy Tech downloads of all current policies for disaster preparedness purposes.
Education & Training:
Facilitates and coaches Leadership, team members, and physicians in best practices and process improvements, and provides ongoing education on new standards and regulations to achieve organizational goals.
Communicates changes with the TJC Standards, National Patient Safety Goals, and the accreditation process overall for members of the CSR and Leadership at each hospital. Participates in system-wide educational initiatives (e.g.).
Prepares comprehensive training materials on TJC Standards and CMS regulations as needed as resources for leaders and staff.
Coordinates and directs Tracer Team rounding activity on the Brunswick and Camden campuses.
Utilizes tracer methodology, team reports, and self assessments to maintain an ongoing status of compliance with all standards.
As a member of the Quality Management Department, assists in the implementation and integration of the organization's Performance Improvement Plan across the system.
Manages required quality data for compliance with regulatory and accreditation standards.
Facilitates improvement teams to address regulatory/accreditation compliance based on data gained from tracer activity, rounds, medical record review and internal reporting processes.
Facilitates root cause analysis (RCA) and failure mode and effects analysis (FMEA) teams to resolve safety issues.
Utilizes effective Meeting Management techniques for team facilitation.
Patient Safety Services:
Responsible for Safety program development and implementation.
Accountable for the facilitation of the employee Patient Safety Survey; including communication, awareness raising to encourage participation, analysis of results and preparation of reports to leadership, medical staff and team members.
Facilitates action planning and follow-up to improve outcomes.
Manages the assessment of compliance with the National Patient Safety Goals, ensuring that policies and practices are in line with TJC standards.
Works with the Quality Management Director in the design, development and implementation of High Reliability concepts system-wide.
Identifies opportunities to improve patient safety through collaboration with the Risk and Legal departments who identify safety and risk concerns through the system's incident reporting system.
Facilitates Rapid Cycle improvement teams to address identified patient safety risks and conducts Failure Modes Effects Analysis (FMEA) for new processes being implemented and for "near miss" events identified through risk reporting.
Leads the organization in the identification of new safety initiatives as identified by accrediting and regulatory bodies.
Education - Minimum Bachelor's degree in a healthcare related field, or Graduate of a Bachelor's or Master's School of Nursing.
Minimum five (5) years' experience in managing healthcare accreditation programs and/or experience in working in a hospital quality department with responsibility for managing accreditation.
Upon completion of two (2) years of experience in the position, individual will be expected to obtain certification from The Joint Commission as a Joint Commission Certified Accreditation Professional.
Must possess strong leadership skills (i.e., task completion, motivation) and be able to plan, develop, implement, and evaluate programs.
Requires the ability to manage multiple programs and projects. Knowledge of statistical analysis & display, data management and performance improvement tools.
Strong interpersonal skills in order to work collaboratively with others in various positions throughout the organization.
Must be comfortable in presenting to groups and committees at Board, Medical Staff, Executive and staff meetings.
Knowledge of and proficiency in QI tools and techniques, including; team facilitation, statistical process control, including process variation, data analysis, skill in facilitating causal analysis including RCA and FMEA processes.
Possess strong analytical skills.
Ability to communicate clearly, verbally and in writing. Interpersonal skills required to interact and partner at various levels, both internal and external, on behalf of the Health System.
Organized and detail-oriented; capable of handling multiple priorities, and working independently.
Express a supportive, customer service-oriented attitude with a demonstrated ability to attain results.
All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, gender expression, or national origin. EOE/AA: M/F/D/V