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Accreditation Specialist - Safety and Quality

St. Francis Regional Medical Center

St. Francis Regional Medical Center

Quality Assurance
Shakopee, MN, USA
Posted 6+ months ago

Number of Job Openings Available:

1

Date Posted:

November 20, 2023

Department:

16002240 Regional Safety and Quality

Shift:

Day (United States of America)

Shift Length:

8 hour shift

Hours Per Week:

40

Union Contract:

Non-Union

Weekend Rotation:

None

Job Summary:

Provides regulatory program support at the business unit level. Partners with site teams to analyze and operationalize accreditation, certification, and regulatory requirements to ensure compliance, and incorporate high-reliability principles and tools into these efforts. Partners with colleagues to lead the development, implementation and evaluation of site accreditation, certification, and regulatory initiatives. Supports data analysis, gap assessments, and presentations related to priority accreditation, certification, and regulatory standards, as well as processes and projects at the site level. Partners with Physician and Clinical and Operational Leaders to mobilize teams to improve compliance with accreditation, certification, and regulatory standards to optimize patient outcomes.

Key Position Details:

  • Will support St. Francis, New Ulm, Owatonna and Faribault
  • No weekend rotation
  • Benefit Eligible

Job Description:

Principle Responsibilities

  • Participates in system and site policy and procedure development, revision and implementation to ensure alignment with accreditation, certification, and regulatory standards.
    • Assists in identifying existing and needed processes and procedures and supports policy updates.
    • Supports teams to develop or revise policies and procedures.
    • Collaborates with key stakeholders to reliably implement policies and procedures in alignment with safety and quality principles and practices.
  • Possesses and provides entry-level knowledge in accreditation, certification, and regulatory to perform tasks and address problems.
    • Serves as a resource to ensure accreditation, certification, and regulatory compliance.
    • Assesses and analyzes accreditation, certification, and regulatory requirements and compliance.
  • Partners with colleagues to develop and implement processes to meet accreditation, certification, and regulatory standards, reduce duplication of efforts and gain efficiency in the program.
    • Guides site accreditation, certification, and regulatory processes including internal surveys, application updating, system contracts, and internal tracers.
    • Supports a sustainable approach to compliance.
    • Participates in internal surveys.
    • Participates in external regulatory surveys.
  • Assists colleagues to provide guidance and support to business unit leadership, clinical and departmental teams in functional area.
    • Incorporates HRO principles and improvement tools into accreditation, certification, and regulatory project implementation and sustainment.
    • Uses problem-solving skills from work experience and applies these skills to support stakeholders in decision-making.
    • Other duties as assigned.


Job Requirements

  • Bachelor's degree Nursing, Public Health, Pharmacy, Health Care Administration, Engineering or other health care related field required required
  • 0 to 2 years experience in accreditation, certification, and/or regulatory required (actively leading survey readiness or formal accreditation, certification, regulatory role) required and
  • 2 to 5 years healthcare experience in related field required


Physical Demands
Sedentary:
Lifting weight Up to 10 lbs. occasionally, negligible weight frequently