Director of Accreditation, RN | DNV Expertise Required | Greater Chicago
We have an immediate opening for a Director of Accreditation. Our client is a non-profit, award-winning, short term acute care facility focused on providing high quality and compassionate health care services by partnering with patients, families, employees, physicians, and the community. The staff declares that it’s a great place to work, where everyone supports each other like family!
This is an excellent opportunity to expand your career and enhance your lifestyle; a vibrant city location that boasts both historic neighborhoods combined with the best of modern living. You can take full advantage of world-class museums, lively shopping districts, a thriving arts community and culture scene, and the various attractions, events, and recreational activities happening throughout the city, every single day. The residents of this area enjoy a very active and diverse social and cultural environment. Housing options vary based on your desired location with both city and suburban options. There are a variety of options for public and private schools, as well as higher education.
• DNV Accredited Acute Care Hospital
• Ensures that corrective and preventative actions are implemented and evaluated for effectiveness
• As part of the Quality Management System for addressing performance improvement and patient safety, the Director of Accreditation proactively seeks out beneficial Quality Improvement Organizational Cooperative projects. If hospital leadership enters into QIO projects, oversees project performance, and ensures that accurate information and supporting documentation is provided to the QIO
• As part of the Quality Management System for addressing performance improvement and patient safety, the Director of Accreditation will recommend and oversee applicable Quality Matrix changes as well as lead/and or participate in kaizen activities related to these improvements
• Serves as a DNV and regulatory content expert to members of the MET/leadership team and staff at large
• Completes ISO9001 gap analysis and subsequent action plan development and execution
• Ensures compliance with the ISO 9001 standard within three years after the initial deemed NIAHO accreditation
• Ensures ongoing compliance and continual readiness with all DNV, CMS, and regulatory body requirements
• Creates and ensures that the organizations documented information (documents and records) determined to be necessary for the effectiveness of the QMS are structured and/or maintained in a manner to ensure availability and suitability of use, when and where needed
• Teaches others to conduct an internal review of its processes and resultant corrective/preventative action measures for implementation and verification of effectiveness
• Identifies and monitors Quality Management System nonconformities. Creates a mechanism to document and monitor actions taken to address improvement and changes
• Promotes and teaches staff/leaders at all levels on a risk-based approach to Quality Improvement. Able to demonstrate evidence of necessary processes and controls of organizational-wide risk-based thinking campus-wide
• Provides management, oversight, and leadership, in the development and implementation of regulatory strategies; including all policies and associated processes
• Utilizes, integrates, and interprets data to assist the Hospital in its improvement efforts and promote optimal patient outcomes
• Completes at a minimum, an annual review of Quality Objectives and the Quality Management System. Analyzes results, completes a gap analysis if required, and collaborates with stakeholders on QMS improvement plan. Ensures appropriate information has been submitted to the Quality Management oversight group, QSC, for determination of the effectiveness of the Quality Management System
• Facilitates and directs organizational-wide risk assessments to ensure compliance with statutory mandates, regulatory requirements, and accreditation standards of professional organizations
• RN (Registered Nurse) required
• Minimum of five years of acute care hospital DNV accreditation experience required
• ISO 9001 Compliance/Certification preferred
• Current BLS certification
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