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Job Type:
RegularScheduled Hours:
40Job Summary:
The Patient Safety and Accreditation Services Specialist will assist the Director of Patient Safety and Accreditation Services in developing, implementing, analyzing, coordinating and evaluating patient safety initiatives and accreditation assessments to encourage a culture of safety to reduce health care errors and risks. This will include participation in data analysis, chart reviews, root cause analysis, focus studies specific to patient safety goals, staff/patient education, patient safety visits, and leading patient safety initiatives. The position also includes on-call response to any survey conducted by outside agencies at Saint Elizabeth Healthcare and its entities. The Patient Safety & Accreditation Specialist will act as a system expert and educator on all relevant Patient Safety and Accreditation standards.This position will demonstrate respect, dignity, kindness and empathy in each encounter with all patients, families, visitors and other employees regardless of cultural background.
Job Description:
- Analyze and coordinate patient safety and accreditation activities to achieve continuous survey readiness, including conducting tracers, mock surveys, and developing and disseminating reports of those activities. Participates with multidisciplinary patient safety and accreditation projects and assists with the completion and coordination of all pre -, intra -, and post - survey activities such as applications, agendas, ESCs, and MOS. Assists with maintaining and updating the Joint Commission Accreditation applications which includes the removing and/or adding new sites of service. Assists in the monitoring of patient safety and accreditation reported data, prepares graphs and power points, and assists with the follow-up and resolution of any cited deficiencies from an accreditation or licensure visit.
- Coordinate RCAs and system reviews which includes chart review, timeline creation, scheduling, completing the required documents, and action plan follow up at 3, 6, and 9 months.
- Under the direction of the Director of Patient Safety & Accreditation Services supports the healthcare system in the Joint Commission and other regulatory surveys as required, coordinates the annual ICM process including reviewing current policies/procedures for standards compliance.
- Under the direction of the Director of Patient Safety & Accreditation Services develops and writes reports specific to patient safety and accreditation and communicates the information to specific areas as requested. Attends and often conducts meetings. Collaborates professionally with staff and managers of the Healthcare System in addressing and resolving patient safety and accreditation issues.
- Performs other duties as assigned.
Education, Credentials, Licenses:
- Bachelors degree in Nursing or other healthcare related field
- Current license as a Registered Nurse in the state where work is being performed
Specialized Knowledge:
- Knowledge of Accreditation standards.
- Knowledge of Patient Safety.
- Knowledge of Patient Safety standards.
- Excellent verbal and writing skills.
- Ability to present informational material and information to small and large assemblies.
- Knowledge of computer programs, MS Office products and EPIC.
- Ability to formulate and lead collaborative teams.
- Ability to organize and define problems, develop strategies and carry out actions.
- Advanced analytical skills to trend and analyze qualitative and quantitative data.
- Capable of exercising sound judgment and making independent decisions.
- Ability to adapt to a complex organizational environment.
- Ability to promote and maintain positive relationships with internal and external customers.
- Leadership ability required to garner cooperation, confidence and respect from administration, colleagues and staff.
- Familiarity with change management.
- Ability to perform and analyze professional medical research and evidence based practices.
Kind and Length of Experience:
- 3 years experience in Acute Care Hospital setting and knowledge of accreditation and patient safety initiatives and evidence based practice guidelines.
FLSA Status:
ExemptRight Career. Right Here. If you're looking for the right careers in healthcare, the right place to be is at St. Elizabeth. Join us, and you'll take pride in the level of care we offer our community.
