Accreditation Coordinator - Performance Improvement

ChristianaCare is currently seeking an Accreditation Coordinator for the Performance Improvement department. In this role, the selected individual will serve as an organization-wide liaison for the System Accreditation Survey Process as well as all other Health Services Accreditations by assisting leadership and other system-wide customers in interpretation and application of Joint Commission and other regulatory standards.

• Assesses compliance with related TJC accreditation and other regulatory standards throughout the system, with an emphasis on ambulatory practice and outpatient sites.
• Participates in ambulatory practice rounds for the purposes of surveying to assess compliance with environment of care, life safety and TJC accreditation standards and provides feedback to local site and leadership for action planning.
• Participate in ongoing compliance assessment activities in partnership with practices and ambulatory services.
• Identifies potential compliance issues based on system rounds and tracer activities.
• Assist in Joint Commission survey, CMS survey and other regulatory surveys in partnership with departmental leadership.
• Assist with preparation of action plans in response to accrediting organization and State/CMS surveys.
• Develops and establishes organizational policy, procedures and processes as needed for regulatory and accreditation requirements to assure organizational compliance.

Requirements:

• BSN required
• Masters degree preferred
• Current Delaware/Compact RN Licensure
• Minimum of 3 years of work experience as professional nurse, Outpatient or Ambulatory experience preferred.
• Certification in National Association for Healthcare Quality preferred or within 1 year of hire.
• Education and or experience in one or more of the following is preferred: performance improvement, process and FOCUS-PDCA methodology, clinical pathways/guidelines, outcomes analysis, TJC or other regulatory accreditation processes, project management and team facilitation.