Accreditation Specialist Resume Example

40 Hours per week; Health Technician; GS-0640-07, Permanent Appointment employee; Naval Hospital Camp Lejeune, 100 Brewster Blvd, Camp Lejeune, NC 28547.

• Supervisors: Lewis S. Oatman (910) 450-2623, CDR Angela Harbor (910) 450-4133 or CDR Harriett Bates (910)450-4231; may contact supervisors.As a command consultant for Joint Commission survey readiness, preparedness, and compliance to not only help evaluate the organization, but to also provide education and guidance that will help staff continue to improve command performance and provide our consumers the highest level of service.
• Command subject matter expert related to current Joint Commission standards, examination of current processes, policies and procedures relative to the standards and preparation to improve any area not currently in compliance.Provide administrative, educational i.e. JC Readiness Booklet, technical support and serve as a consultant to staff pertaining to The Joint Commission Accreditation Standards.Demonstrate proficiency in simplifying the Joint Commission survey process.
• Continually review command instruction and maintain a current and complete set of instructions, reports, and other pertinent data that is organized according to The Joint Commission functions. Solely responsible for ensuring new Joint Commission standard updates are distributed to all command staff members. Help facilitate a continuous accrediting process by incorporating an additional form of evaluation.
• Ensure the Joint Commission E-Edition manual is current and available to all staff members. Prepare the command's Joint Commission (JC) Application to request a survey.Compile data for The Joint Commission accreditation activities to include electronic application, periodic reviews of standards, tri-annual survey as well as reports and or data collection deemed appropriate by the Quality Manager. Compile required information and submit application for Department Head review and Commander's signature.
• Coordinate with appointed Focus Standards Assessment (FSA) champions throughout the organization.FSAs are conducted to ensure the organization is in continuous compliance with all JC requirements and identifies and manages any potential risk.
• Serve as a direct point of contact for Joint Commission ORYX measures. Coordinate quarterly ORYX Abstractor visit, review outlier charts with abstractor and coordinate the ORYX exit brief. Track, monitor and document meeting records, Performance Measures, such as ORYX and Core Measures required by The Joint Commission. Ensure data and information related to ORYX and Core Measure is systematically collected, analyzed, reported and posted in appropriate dashboard within the Quality Management SharePoint.
• Plan and conduct Joint Commission mock survey in the “Tracer Method” and participate as the leader of a member of the mock survey team Conduct training staff in tracer methodology. Oversee and coordinate the efforts and schedule for the Command Tiger Team, which provides comprehensive assessments to the healthcare organization to understand its unique features and needs. Implemented an organizational and unit-specific tracer method process. Implement tracer methodology into ongoing improvement efforts.
• Exclusively responsible for conducting individual and system tracers throughout the medical treatment facility. Perform clinical spaces and record surveys using Joint Commission and other regulatory agency guidelines and determines exceptions against a criteria list utilizing tracer methodology in outpatient and inpatient areas.
• Provide education and instruction to staff on command policies and procedures when actual method does not comply with command or The Joint Commission Standards. Create, develop and implement audit tools regarding command and TJC policies and procedures.
• Coordinate plans for improvements with Department Heads when corrective issues are identified by conducting tracers with the Command Tiger Team and Mini Focus Leadership Rounds.
• As part of the Quality Management Program, provide consultation regarding TJC, data collection techniques, statistical process control methodologies, and processes for reporting continuous improvement activities to staff. Manage the Joint Commission reference library, by ensuring up-to-date instructions and Standards Operating Procedures.
• Assist with Quality Management, Risk Management and Patient Safety reviews and problem investigations as requested and directed by the Quality Manager Department Head. Assist with ongoing education and training of command staff on Quality Management, Risk Management and Patient Safety programs.