Accreditation Director

Job Category:

Executive Leadership

Work Shift/Schedule:

Varies

Northeast Georgia Health System is rooted in a foundation of improving the health of our communities.

About the Role:

Job Summary

The Director of Accreditation will work collaboratively with the Executive Director of Patient Safety & Quality to oversee accreditation activities for the Acute Cares Services of Northeast Georgia Medical Center.This position is responsible for implementing a system and culture of continuous readiness for the hospitals and hospital outpatient departments in the system. A primary focus of the position will be supporting clinical and non-clinical departments in continuous compliance with DNV and ISO standards (including control of documented information and audits) and policy management for the system. He/She will support the Executive Director in ensuring the requirements of the Quality Management System (QMS) for System Level Acute Care Services are determined, implemented, and maintained. The Director leads a team of Accreditation Specialists and Policy and Document Specialists that support the Acute Care Services of NGHS.

Minimum Job Qualifications

• Licensure or other certifications: Current license to practice as an RN in GA

• Educational Requirements: Bachelors Degree.

• Minimum Experience: Minimum of five (5) years of progressively experience in a hospital environment, including experience in management. Minimum of 5 years of Accreditation experience (preferably DNV and/or ISO) or related experience in a healthcare environment.

• Other:

Preferred Job Qualifications

• Preferred Licensure or other certifications:

• Preferred Educational Requirements: Masters Healthcare Administration, Business Administration or Organization Leadership.

• Preferred Experience: Experience with policy management.

• Other:

Job Specific and Unique Knowledge, Skills and Abilities

• Strong written and verbal communication skills

• Strong organizational skills

• Excellent interpersonal and facilitation skills

• Knowledge of local, state and national accreditation requirements and survey activities

• Knowledge of ISO requirements, including control of documented information.

• Ability to prioritize duties and projects; willing to work flexible hours to meet the needs of the department.

Essential Tasks and Responsibilities

• Leads the continuous readiness and accreditation processes for the System Acute Care Hospitals, specifically CMS, DNV, Georgia Rules and Regs, and ISO.Reports and communicates findings, facilitating the completion of action plans, and monitoring.

• Works collaboratively with nursing, operations, Risk, and other departments to proactively identify areas of opportunity, and to implement systems to support improvement and continuous patient and survey readiness.

• Organizes the Accreditation team to support specialty-specific survey and certification activity.

• Manages policy and document control processes for system, including Policy Steering Committee oversight. Collaborates with others in the organization to promote consistent and standardized operations related to document control.

• Maintains administrative/strategic oversight for the document control system and oversees current and standardized operations within the system.

• Contributes expertise to hospital/system and medical staff committees, including meeting coordination and facilitation, as requested.

• Communicates and/or escalates unresolved issues, following established policy.

• Reviews and manages contracts pertaining to role functions, as assigned.

• Recognizes and operationalizes work needed to support annual pillars/goals.

• Collaborates with the Executive Director to determine fiscal requirements, preparing budgetary recommendations.

• Ensures that staff are current in competency, assessments, licensure, certifications, and other annual training.

• Completes special projects or assignments, as requested.

• Leads as a lean leader by upholding Quest for Excellence Principles

•  13A Oversees daily management system deployment for all areas of responsibility

•  13B Maintains high proficiency in Quest for Excellence behaviors and tools

• Assesses, coaches, and evaluates staff’s level of performance. Providing daily and periodic guidance, support, and resources to departmental staff to facilitate high quality performance and achievement of organizational goals

Physical Demands

• Weight Lifted: Up to 20 lbs, Occasionally 0-30% of time

• Weight Carried: Up to 20 lbs, Occasionally 0-30% of time

• Vision: Moderate, Frequently 31-65% of time

• Kneeling/Stooping/Bending: Occasionally 0-30%

• Standing/Walking: Frequently 31-65%

• Pushing/Pulling: Occasionally 0-30%

• Intensity of Work: Occasionally 0-30%

• Job Requires: Reading, Writing, Reasoning, Talking, Keyboarding, Driving

Working at NGHS means being part of something special: a team invested in you as a person, an employee, and in helping you reach your goals. 

NGHS: Opportunities start here.

Northeast Georgia Health System is an Equal Opportunity Employer and will not tolerate discrimination in employment on the basis of race, color, age, sex, sexual orientation, gender identity or expression, religion, disability, ethnicity, national origin, marital status, protected veteran status, genetic information, or any other legally protected classification or status.