Quality Accreditation & Patient Safety Coordinator
Moses Cone Health System - Greensboro, NC

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Education / Licensure / Certification:
Education: Bachelors degree in a healthcare related field required, Masters Degree preferred

At least 3 years experience in the healthcare setting, previous experience with
Regulatory compliance preferred
Experience in data analysis
An equivalent combination of education and experience may be considered.

Job Description:

This role is responsible for assisting the organization with ongoing programs to promote continuous accreditation readiness and patient safety improvement for assigned facility(s)


1.Leads continuous readiness efforts and coaches others in the development of accreditation and patient safety improvement capabilities; provides direction to department and facility leadership in the planning of a systematic, organization-wide approach to continuous accreditation readiness and patient safety improvement; assists with the planning and execution of TJC annual PPR

2.Maintains expert competence in accreditation (e.g. TJC, CMS, DHSR, DHEC, CARF, OIG, CAP, as applicable) standards and communicates relevant changes to appropriate leaders and staff

3.Maintains a close working relationship with facility leadership to optimize patient safety culture and to support constant state of readiness for accreditation reviews

4.Facilitates assessments, develops, implements and evaluates corrective action plans based on past surveys and preparatory tracer activities; compiles and distributes compliance reports including appropriate action plans to facility oversight councils; supports and guides the facility in continuous survey readiness efforts

5.Serves as a technical resource and subject matter expert, overseeing all aspects of survey and surveyor activity, including coordinating content from others on the Cone Health readiness team

6.Coordinates department and facility accreditation and patient safety readiness meetings, analyzes trends of performance metrics, identifies opportunities for improvement, develops action plans, measures success of these action plans and creates the records and follow-up metrics for each meeting and activity; reassesses approach to maximize success

7.Assist leadership in defining key performance indicators and developing measurement tools to evaluate patient safety process improvements; coordinates patient safety culture assessment efforts

8.Coordinates FMEA process and other patient safety metrics to include assisting with RCAs

9.Consults with and trains staff to implement monitoring and measurement tools

10.Provides education and training on accreditation matters

11.Works collaboratively with Cone Health resources to achieve facility and system accreditation and patient safety goals

12.Performs other duties as assigned

As employees of Cone Health System, our behaviors must be aligned with our values of Outstanding Services, Caring Spirit, Innovative Climate, Integrity and Financial Viability. Our Standards of Behavior reinforce these corporate values and reflect our commitment to Service Excellence. Our Standards of Behavior are: 
Maintain a professional appearance 
Demonstrate a positive attitude to all customers and fellow employees. 
Maintain a safe, clean and attractive environment 
Communicate with compassion and courtesy 
Anticipate customer needs 
Maintain patient privacy and confidentiality

Must have the ability to clearly communicate verbally, in person, and in writing with patients, families/agencies and the health care team; must possess a strong sense of urgency and make sound decisions

Must be computer literate; intermediate to advanced computer skills with demonstration of skill and competence in use of all Microsoft Office applications preferred

Ability to analyze data

Ability to clearly communicate through both verbal and written formats

Ability to analyze work processes for possible performance improvements

Required to move about the various sites of Cone Health System including prolonged periods of standing, sitting, and walking

Ability to type, write, stoop, observe, count and conduct interviews throughout the health system

Physical job demands may be modified to reasonably accommodate individuals with disabilities

Must be able to work with a minimum of supervision

Cone Health - 16 months ago - save job - copy to clipboard
About this company
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Cone Health (formerly Moses Cone Health System) serves patients in central North Carolina through five acute and specialty care hospitals...