Coordinator-Accreditation Certification (Cardiac and Vascular programs)

Future State Job Title:

Accreditation Specialist Senior

JOB SUMMARY

The Certification Coordinator, under the direction of Accreditation and in collaboration with Quality, Service Lines, Providers, Leaders and Peers, coordinates process(s) to achieve initial compliance, maintain ongoing compliance with certification and accreditation standards and maintain ongoing survey-readiness. Completes data collection and submission to registries as indicated. Works with teams to develop, implement, and monitor effectiveness of process improvement as directed. Utilizes a systematic approach to ensure KDMC aligns with King's Daughters Health System (KDHS) processes to provide safe, quality care and to achieve and maintain compliance with accreditation, certification, and regulatory requirements.

DUTIES AND ESSENTIAL FUNCTIONS

Maintain an environment committed to the highest standards of quality care, patient safety and customer service by identifying and implementing innovated approaches to improving care. Work collaboratively within the service line to review current processes and make recommendations for improvements throughout the continuum of health care services from the pre-operative assessment to post-acute care. Participates in community events with service lines as it applies to achieving or maintaining DSC certification(s). Promote a positive work environment which emphasizes respect to our customers, patients and their families, physicians, staff and other departments. Works with certification teams in the: Planning, development, and implementation of program goals and operations. Coordination and survey process of surveys conducted by the Joint Commission and other regulatory agencies focused on clinical care and safety. Process improvement activities required to maintain ongoing compliance, continuous survey-readiness, survey preparation, survey coordination, post-survey follow up and ongoing monitoring for KDMC as indicated by survey results. Review of current policies, development of policies and procedures as they are related to compliance with regulatory and accreditation guidelines, as assigned. Exhibits vision with regard to long range plans for service lines when working with teams to achieve initial certification and maintain Disease Specific Care. Functions as a change agent by helping to successfully implement management decisions and other hospital and departmental changes and objectives. Assists with the development, review, and provision of educational material, as assigned, including: New employee orientation material as it relates to certification and accreditation standards Mandatory educational material to meet new certification/accreditation requirements Mandatory educational material to meet annual requirements Specific educational material to address areas of areas of identified vulnerability, knowledge deficit, and unique requirements for specific certifications and accreditations.

EDUCATION/LICENSE/CERTIFICATION/OTHER REQUIREMENTS

Minimum requirement: Associates Degree in Nursing or Imaging Maintains applicable clinical licensure in the state of Kentucky and other states as required Five years of experience in a cath and/or vascular lab. Experience in data collection and process improvement Experience providing in-service education for hospital staff as well as presentations for community/public. Excellent organizational, oral and written communication skills, self-learning skills, problem solving, computer skills, and team building skills.

Preferred qualifications:

Bachelor's degree Experience with analysis of accreditation standards and policies Knowledge of accreditation and certification standards and/or policy formulation Experience with program development

WORKING ENVIRONMENT

Works indoors in an office/clinic setting The noise level is usually moderate

PHYSICAL DEMANDS

Constantly required to maintain a stationary position behind a computer. Frequently required to move about inside the department. Constantly required to communicate telephonically and face to face with colleagues and customers. Constantly required to operate a computer and telephone. Constantly required to lift and/or move up to 10 pounds. Frequently required to lift and/or move up to 25 pounds. Occasionally required to lift and/or move up to 50 pounds Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, and depth perception