What are the responsibilities and job description for the Director of Accreditation position at 100 Albany Med Health System?
Department/Unit: Quality Management Work Shift: Day (United States of America) Salary Range: $119,397.28 - $191,035.65 The Director of Accreditation and Certification implements, directs and facilitates activities that support the institution's ability to achieve and remain a successfully accredited health care organization that is continuously ready for patients every day. For accreditation and certification survey related activities, the director will serve as the on-site survey leader, as a resource and consultant to the organization, as a liaison between the hospital and the accrediting organization, and as an expert in continuous improvement processes. This role reports to the Associate Vice President of Accreditation and Quality and supervises accreditation team members. Essential Functions Directs all organizational Continuous Survey Readiness Activities which include managing, facilitating, or coordinating the following activities Directing the completion and submission of accreditation/certification administrative activities in collaboration with operational partners Coordinating an ongoing readiness assessment Updates accreditation and certification portal to reflect hospital’s services Prepares for all accreditation and certification on-site surveys (together with real-time coordination, facilitation and follow-up) Preparing the organizational response to unannounced accreditation on-site surveys Provides staff education andtraining Consults on and interprets standards (CMS, New York State Department of Health and Accreditation) Communicates accreditation/certification/regulatory information Collaborates with others in continuous improvement processes, including data collection, analysis and reporting Collaborates with others in policy and procedure development and review Development of tools(checklists, data collection forms) for conducting individual auditsa nd assessment surveys Oversees the collection and distribution of audit data Collaborate with the professional education department on the development and distribution of materials related to standards compliance Development and distribution of periodic communications to update organizational leaders and staff on new quality/safety issues or initiatives, on-site survey information and any changes to standards or the interpretation of accreditation/certification standards Participates in employee orientation activities as required by the organization Provides education to staff as needed regarding new quality/safety initiatives Conducts periodic meetings with managers to update their knowledge of accreditation standards and regulatory/organizational issues and trends uncovered during readiness activities Facilitates annual collection of information/data required to participate in Leapfrog’s Hospital Grade. The Director will communicate as needed with relevant staff and leadership to assure successful participation. Facilitates ad hoc performance improvement groups focused on clinical and accreditation standard compliance. QUALIFICATIONS Master's Degree in Nursing or a healthcare-related degree required 7 to 10 years of applicable healthcare experience 5 years in direct patient care nursing Related experience with quality measures accreditation standards, and related compliance processes Thank you for your interest in Albany Medical Center! Albany Medical is an equal opportunity employer. This role may require access to information considered sensitive to Albany Medical Center, its patients, affiliates, and partners, including but not limited to HIPAA Protected Health Information and other information regulated by Federal and New York State statutes. Workforce members are expected to ensure that: Access to information is based on a “need to know” and is the minimum necessary to properly perform assigned duties. Use or disclosure shall not exceed the minimum amount of information needed to accomplish an intended purpose. Reasonable efforts, consistent with Albany Med Center policies and standards, shall be made to ensure that information is adequately protected from unauthorized access and modification. Albany Medical Center is the centerpiece of medicine, research, and medical education in New York’s Capital Region and is the area's largest private employer with more than 10,000 employees. Albany Medical Center offers excellent career opportunities in a wide range of roles in both patient care and administration. We value all our staff members and offer outstanding employee benefits including: · Excellent health care coverage with no copay at Albany Medical Center providers · A wide array of services and programs to support emotional, physical, and mental wellbeing Anchored in the state’s historic capital city, Albany Medical Center offers a full range of inpatient and outpatient care and is home to the region’s largest hospital, only Level 1 adult and pediatric trauma centers, and only children’s hospital. The downtown campus also offers opportunities at Albany Medical College. Albany Medical Center, along with Columbia Memorial Health, Glens Falls Hospital, Saratoga Hospital, and the Visiting Nurses, form the Albany Med Health System, serving more than three million people over 25 counties.
Salary : $119,397 - $191,036