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.
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.
Internal Number: JR55244
About Christiana Care Health System
Christiana Care Health System is headquartered in Wilmington, Delaware and is one of the country's largest health care providers, ranking 21st in the nation for hospital admissions. Christiana Care is proudly a Nurse Magnet recognized institution. Christiana Care Health System is also one of the largest health care providers in the mid-Atlantic region, serving all of Delaware and portions of seven counties bordering the state in Pennsylvania, Maryland and New Jersey. A not-for-profit, non-sectarian health system, Christiana Care includes two hospitals with more than 1,100 patient beds, and is a major teaching hospital with two campuses. Christiana Care is continually recognized for excellence on a regional and national level. Our role in the community is expressed in the Christiana Care Way: "We serve our neighbors as respectful, expert, caring partners in their health. We do this by creating innovative, effective, affordable systems of care that our neighbors value."Christiana Care is a great place to work because we value diversity and recognize it to be a core part of our success. Because of the diversity of our employees, affiliated health professionals and volunteers, we are... positioned to meet the unique needs of our patients and community. We acknowledge and celebrate the uniqueness and talent of each employee. Because of our talented workforce we are able to provide a quality healthcare experience to our patients and community. We strive to create an inclusive environment in which individual diversity can be leveraged and thrive. Christiana Care Health System is an equal opportunity employer, firmly committed to prohibiting discrimination, whose staff is reflective of its community and considers qualified applicants for open positions without regard to race, color, sex, religion, national origin, sexual orientation, genetic information, gender identity or expression, age, veteran status, disability, pregnancy, citizenship status, or any other characteristic protected under applicable federal, state, or local law.