Accreditation Coordinator RN
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Shawnee, KS 66217
Accreditation Coordinator AdventHealth Shawnee Mission
Location Address: 9100 W. 74th Street, Shawnee Mission, KS 66204
Top Reasons To Work At AdventHealth Shawnee Mission
- Providing faith-based, whole person care to Kansas City since 1962
- Excellent health benefits, an onsite child care center and fitness facility
- Tuition reimbursement to support continuing education
- Employee Referral Program
- Largest health care provider in Johnson County with three campuses
Full Time, Days
- Utilizes the Performance Improvement Model
- Utilizes excellent interpersonal skills to deal with challenging situations while maintaining strong supportive relationships.
- Readily available for questions; handles requests in a courteous and respectful manner.
- Communicates effectively, both written and verbally.
- Demonstrates a proactive attitude and seeks to remedy situations before mistakes are made or corrects errors when found; takes responsibility for the overall quality image of the department.
- Ensures accuracy of data collection and submission; validates integrity of data collected.
- Develops data reports for projects, committees, hospital departments, medical staff departments, as designated.
- Knowledge of and utilizes statistical approaches, measurement techniques, including benchmark and comparative data to develop quality reports.
- Collects, aggregates, analyzes, summarizes and reports quality data for hospital organizational performance and physician performance data as indicates.
- Participates in hospital-wide outcomes and quality improvement initiatives/ performance improvement teams.
- Assists in efforts to improve and streamline the process and workflow of the department.
- Demonstrates the ability to set appropriate priorities.
- Recognizes how absence impacts the functioning of the healthcare team and strives to minimize this effect.
- When requested, is willing to adjust personal schedule in order to complete workload when necessary
- Attends educational offerings as needed to promote continuous learning and support to department
- Responsible for staying current on CMS Conditions of Participation (CoP) and Joint Commission standards for all levels of care.
- Responsible for Joint Commission Accreditation/CMS CoP Compliance
- Ensures continuous survey readiness/compliance with accreditation standards.
- Conducts or coordinates MOCK surveys, tracers, rounding, compliance audits,
- Conducts and abstracts chart audits of documentation e.g. clinical pertinence for the medical staff, open records reviews, critical test results, etc.
- Conduct Focused Standard Assessment for accredited programs
- Communicates with and educates associates and medical staff on Joint Commission standards
- Facilitates and coordinates changes necessary to remain compliant-“ever ready activities”
- Responsible for on-site survey activities (preparation, planning, coordinating, etc.)
- Serves as a liaison between AHSM’s accredited programs and the Joint Commission
- Communicates and facilitates necessary changes in order to remain continuously compliant with accreditation standards.
- Collaborates with other hospital leaders in developing, monitoring, reporting and analyzing accreditation efforts.
- Proactively seeks opportunities/mechanisms aimed at continually improving patient care, processes and compliance.
- Recommends and facilitates change to improve based on identified risks.
- Facilitates the creation of an effective action plan in response to identified issues.
- Responsible for follow through and oversight for completion and actions plans relating to identified issues, including follow up measures of effectiveness.
- Working knowledge