Job Description

JOB SUMMARY:
The Accreditation/ISO Coordinator is a key participant in the hospital's continuous accreditation and regulatory readiness program. Responsible for providing direction and oversight for regulatory and accreditation compliance including DNV, ISO 9001 Quality Mgmt System Requirements, and State and Federal agencies. This individual assists in maintaining preparedness for accreditation and licensure surveys.

EDUCATIONAL REQUIREMENTS
Requires Bachelors degree or equivalent in nursing or other healthcare related field. Master's degree preferred.

CERTIFICATION & LICENSURE REQUIREMENTS
Basic Certificate in Quality & Safety (IHI) within 1 year.

EXPERIENCE REQUIREMENTS
Five years of experience in the healthcare industry required with significant experience in clinical operations and/or process improvement. Previous accreditation/regulatory readiness experience preferred.

ESSENTIAL FUNCTIONS:

• Conduct gap analyses and develop evidence-based corrective action plans to assure compliance with regulatory standards.
• Facilitate monthly accreditation education session to include agenda planning, minutes, and presentations as needed.
• Organize an interprofessional team to serve as chapter leads for accreditation standards.
• Executes survey readiness program, including mock surveys and tracer methodology preparations.
• Provides consultation to organization leaders on survey readiness and NIAHO standards.
• Updates leaders on new standards and assures effective communication of expectations.
• Assist in assuring accuracy and timeliness in submission of corrective action plans to external agencies and internal stakeholders.
• Responsible for developing ISO internal audit strategy and oversight, and implementation of ISO strategic plan.
• Provides oversight of the organization's policies and procedures software system.
• Conducts training on the policy system.
• Communicates policy updates to staff and leaders.
• Tracks policy and procedure compliance.
• Manages policy and procedure review cycle to ensure documents are reviewed per policy.
• Revises documents as requsted by policy owners.

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