Accreditation Program Manager | Massachusetts
Our client is a nationally recognized, growing, teaching hospital. This is an opportunity to work at a facility whose leaders have great vision and a staff focused on providing quality patient care. It offers a family atmosphere, where everyone works as a team. This is a great environment to build your skills, apply your experience and advance your career.
The area is steeped in history and known for local access to the arts, exceptional restaurants, and outstanding shopping. Top notch schools and high quality of living; the residents have a deep sense of pride and respect for their community. Cultural events, entertainment activities and natural attractions abound!
Key Responsibilities and Duties:
• Designs and implements a systematic approach to ensure a high level of awareness and compliance with accrediting agency requirements throughout the hospital including ramifications of failures in compliance
• Serves as the expert resource for TJC accreditation standards and the Centers for Medicare and Medicaid (CMS) Conditions of Participation (COPs) and expectations for compliance
• Will guide the development of policies, procedures, practices and guidelines as they relate to the hospital compliance
• Provides oversight and direction for the hospital’s Policy and Procedure Committee that oversees hospital policies, procedures, related forms, provider order sets and informed consent documents
• Works closely and collaboratively with medical, nursing and clinical and non-clinical personnel and leadership to implement improvement strategies to assure continual readiness
• Serves as Chair of the Accreditation oversight group
• Coordinates survey processes with external groups and internal surveys
• Participates in Performance Improvement activities including Root Cause Analysis or Healthcare Failure Mode and Effect Analysis (HFMEA)
• Implements solutions borne out of Root Cause Analysis or HFMEA
• Certified Professional in Healthcare Quality (CPHQ) preferred
• Lean certification and experience preferred
• Five to seven years of relevant experience in hospital health care quality, patient safety, and/or risk management required
• Three to five years of supervisory or management experience preferred
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