Full-Time
DHR Health Clinics

POSITION SUMMARY:

The Clinic Accreditation Coordinator works with the Medical Staff to identify peer review indicators for each of the specialties and analyzes those screens against patient documents against those indicators, and Core Measures indicators, and brings certain cases to the Medical Staff for their review and action. The Coordinator also works with Quality Improvement initiatives. Working in a collaborative environment as a compliance liaison with medical and hospital patient care staff in ensuring quality patient care and compliance with Texas state law, CMS and TJC requirements through compliance program design, and data collections, analysis and presentation.

• Must have strong organizational skills and be able to work independently.
• Ability to communicate clearly and concisely with all levels of nursing, administration, and physicians
• Ability to read, write and speak English
• Evening or weekend work may be required
• Position requires travel, valid driver’s license and vehicle insurance are required
• Must maintain current knowledge of Texas state law and TJC regulations
• Requires experience in performance improvement methodologies; quality measurement; and data analysis using statistical principles
• Working knowledge of CMS as applicable to compliance
• Working knowledge of quality improvement principles and methodologies utilized in health care
• Commitment to the basic philosophy of regulatory compliance and ability to embody this philosophy in the work place
• An affirming style of leadership in working with others
• Knowledge of adult education theory and practice and the ability to plan organize and lead educational sessions
• Ability to assess and to explain data from broad perspective
• Demonstrates the ability to manage multiple tasks and projects in a productive manner
• Demonstrates interdepartmental support and teamwork through a supportive and collaborative approach
• Organizes, schedules and conducts internal audit process to measure survey readiness (mock surveys, tracer activities, etc.)
• Tracks and trends regulatory
• Knowledge of PC technologies, including operating and application software

• Facilitates coordination of regulatory compliance activities that includes policy and procedure development, survey preparation, survey management and follow up, assessment of standards compliance and reporting of vulnerabilities to key stakeholders.
• Designs compliance studies, develops criteria for evaluation, and assists assigned hospital departments with appropriate data collection and data analysis
• Reviews and interprets patient care information, discharge summaries, operation reports, and other data sources used to assess quality care issues
• Creates reporting documents for departments to use for tracking compliance activities, trends and patterns, and identifying opportunities for improvement
• Provides education on data analysis and utilization of information to Clinic Accreditation and Joint commission teams
• Educates hospital staff, medical staff, and leadership regarding regulatory requirements/changes
• Attends and may facilitate department meetings, providing input regarding problems identification and resolution, continuous quality improvement (CQI), and other patient care and accreditation activities
• May provide ongoing clinical support to Hospital programs by reviewing and logging charts and incident reports, and recording improvement activities and results
• Assists with developing and maintaining effective, comprehensive continuous compliance programs
• As requested, prepares reports for, and recommends research topics to, the Quality Improvement Committee
• Develops record keeping and reporting functions and maintains appropriate files
• Develops effective data collection and evaluation tools to collect and organize data used in monitoring and continually assess the success of problem resolution activities
• Maintains Compliance Data, as required
• Completes and maintains records for problem status for follow-up
• Maintains and distributes corrective action reminder report to responsible person
• Plans meetings and disseminates information to appropriate areas, as directed
• Compliance issues
• Prepares monthly leadership report regarding regulatory compliance
• Assures measurement of all required TJC standards
• Coordinates all on site regulatory, licensure and accreditation surveys
• Other duties as assigned