Quality and Accreditation Coordinator

Tenet Healthcare; Rock Hill (SC); On-site; USD 65,000 - 95,000; Full time

Benefits offered by this job

Medical, dental, vision, and life保险

401(k) with employer match

Generous paid time off

Career development and continuing教育

Health savings accounts

Voluntary benefits: pet insurance

Voluntary benefits: legal insurance

Voluntary benefits: accident and IIlI

Voluntary benefits: long term care

Voluntary benefits: elder & childcare

Voluntary benefits: auto & home

Job summary

Piedmont Medical Network - Rock Hill Hospital seeks a Registered Nurse with expertise in The Joint Commission standards to lead Continuous Readiness and hospital-wide performance improvement activities. The role coordinates PI initiatives, educates clinical staff, and collaborates with the Medical Staff and Department Managers to ensure regulatory compliance.

The incumbent advises on evidence-based medicine, oversees data collection and audits, and supports policy implementation in a fast-paced

Qualifications

• Experience in The Joint Commission program, Core Measures and Performance Improvement.
• Proficient with using the computer.
• Expert with Word, Excel and PowerPoint.
• RN License or equivalent combination of advanced education and related work experience.
• Multi-State RN License requirements for residents of compact states.

Responsibilities

• Ensure compliance with regulatory and accrediting agencies; monitor state and federal regulations and inform leadership of evolving requirements.
• Disseminate PI findings and reports to Department Director meetings or other communications.
• Support data collection and analysis for patient care quality and corrective actions.
• Develop and coordinate education of staff and physicians on PI initiatives and programs.
• Facilitate policy and procedure data base use and training for department directors.
• Perform related duties as required.

Skills

Joint Commission program experience

Core Measures

Performance Improvement

Computer proficiency

Word

Excel

PowerPoint

Education

Bachelor’s Degree

Job description

Overview

Embark on a rewarding career with Piedmont Medical Network - Rock Hill Hospital. If you are a compassionate healthcare professional eager to contribute to patient care, this is your opportunity where your skills make a difference every day. Join us in delivering exceptional healthcare with a personal touch.

At Piedmont Medical Network - Rock Hill Hospital, we understand that our greatest asset is our dedicated team of professionals. That's why we offer more than a job - we provide a comprehensive benefit package that prioritizes your health, professional development, and work-life balance. The available plans and programs include:

• Medical, dental, vision, and life insurance
• 401(k) retirement savings plan with employer match
• Generous paid time off
• Career development and continuing education opportunities
• Health savings accounts, healthcare & dependent flexible spending accounts
• Voluntary benefits include pet insurance, legal insurance, accident and critical illness insurance, long term care, elder & childcare, auto & home insurance

Note: Eligibility for benefits may vary by location and is determined by employment status

Job Summary

This employee is an expert on The Joint Commission regulatory standards. Responsible for Continuous Readiness Program including hospital wide processes, active audit and inspection program for survey preparedness and compliance with TJC, CMS and other pertinent regulatory standards. Provides house wide support for education regarding regulatory standards. Serves as TJC coordinator for the hospital in conjunction with DCQI. Provides supervision, guidance and assistance with overall implementation, integration and coordination of hospital Performance Improvement program. Is able to independently lead PI processes house wide. Coordinates evidenced based medicine and performance improvement activities of the clinical staff. Assist with development and implementation of strategies aimed at improving performance. Participates in committees associated with Core measures and quality initiatives as needed. Serves as consultant to the Medical Staff Committees and Department Managers. Coordinates with physicians in real time and retrospectively on evidence based medicine and regulatory standards compliance. Participates in the hospital policies and procedures committee and any other committee as assigned. Assists DCQI in the day-to-day operations of the hospital.

Responsibilities

• Compliance with regulatory and accrediting agencies - Monitors pertinent state and federal regulations, standards, and guidelines, as well private initiatives in quality management and improvement analyze implications and inform medical staff, administration and governing board leadership of evolving trends and requirements for compliance.
• Communication and reporting - Assists in dissemination of PI findings and reports as needed for Department Director meetings or through other forms of communication such as house-wide script.
• Data collection and analysis - Provides support for data collection and analysis, including the ongoing systematic screening of data sources and special studies to evaluate patient care quality and impact of corrective actions taken.
• Education and support - Develops and coordinates education of staff and physicians on PI initiatives and Programs.
• Policy and procedure management - Facilitates department directors’ education on Policy and procedure data base, use and requirements of system.
• Performs related duties as required.

Qualifications

• Required:
  • Experience:
    • Experience in The Joint Commission program, Core Measures and Performance Improvement.
    • Proficient with using the computer
    • Expert with word, excel and PowerPoint.
  • Licensure/Certification:
    • RN License or equivalent combination of advanced education and related work experience
    • Any RN license must be valid Permanent Multi-State RN License from the state in which you reside
    • Should you hold a RN license from another Compact state, you are required to apply for and obtain a Multi-State RN License from the state in which you reside within 30 days.
• Preferred:
  • Education: College Graduate, Bachelor’s Degree

Organization Description

Piedmont Medical Network has served the community of York County and beyond for more than 30 years. Piedmont Medical Network - Rock Hill Hospital is a 288-bed facility that has advanced equipment and experienced healthcare staff catering to the diverse needs of the community it serves. Services include preventive care, advanced heart and stroke care, maternity care and a Level III NICU.

Piedmont Medical Network - Fort Mill Hospital opened in 2022 with 100-beds, advanced technology and a compassionate care team. The new hospital features a 24/7 Emergency Department, Intensive Care Unit, Medical/Surgical Unit, and a wide array of Surgical Services and Women's Services.

Piedmont Medical Network has been recognized for its elite level of safety by being awarded the Leapfrog Groups Hospital Safety Score and the Certified Zero Harm Award by SCHA (South Carolina Hospital Association) in collaboration with South Carolinas DHEC. The Cardiac Care program at PMC provides quality care and was designated as a Blue Distinction Center for Cardiac Care by BlueCross BlueShield and a Nationally Certified Cardiac Rehabilitation Program by the American Association of Cardiovascular and Pulmonary Rehabilitation. At Piedmont Medical Network, you can grow your career skills and be a vital member of our team dedicated to improving the health of the community. Join our team!

Employment practices will not be influenced or affected by an applicant's or employee's race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship. Tenet participates in the E-Verify program. Follow the link below for additional information. E-Verify: http://www.uscis.gov/e-verify The employment practices of Tenet Healthcare and its companies comply with all applicable laws and regulations.