Summary

The System Manager of Quality and Accreditation improves the culture of safety by providing leadership, support, and content expertise to system leadership and individual entities on regulatory, accreditation, quality improvement, and patient safety matters. Serves as a knowledge expert on accreditation/regulatory requirements from TJC, CMS, DNV, State. Provides program direction and standardization driven by a framework of quality and applicable regulatory and accrediting requirements designed to improve quality of care and patient safety.

Responsibilities

• Provides proactive leadership and works collaboratively to lead an effective, ongoing system regulatory/accreditation readiness program which enhances quality and patient safety through standards compliance.

• Develops system and individual proactive readiness assessments customized to the individual system entities, performs assessments and provides a written report on areas of vulnerability to entity leadership.

• Assists with development of detailed work plans to address identified vulnerabilities and the resulting quality improvement planning, and monitors the progress of subsequent improvements and new processes resulting from proactive risk identification.

• Collaborates with entity leadership such as CEO, CNO, and Quality Directors to address individual entity requests for assistance in integrating quality improvement efforts, regulatory/accreditation compliance, and operations.

• Participates in system performance improvement projects, initiatives, and strategic goals and provides insight and education into the relationships between regulatory requirements and performance measures which drive reimbursement, cost, and public outcomes such as CMS Star ratings, eCQM, Leapfrog, etc.

• Serves as a knowledge expert on accreditation/regulatory requirements from TJC, CMS, DNV, State. Educates system leaders and initiates system level accreditation and quality initiatives to meet requirements and enhance patient outcomes.

• Provide guidance through use of data to identify entity-specific and system-wide strengths and areas of risk related to regulatory compliance, and assists in using this information to design proactive plans and projects to enhance/mitigate future findings.

• Assists/attends/supports system entities during accreditation/regulatory surveys/"For Cause" complaint visits, and integrates information gained into the system program for improvement in compliance.

• Provides direction, oversight, and assistance to system entities with development and submission of specific corrective action plans necessary after regulatory/accreditation surveys, "For Cause" and complaint visits, or other visits by regulatory bodies such as TJC, CMS, DNV, State complaints or serious safety event investigations.

• Mentors and educates system quality directors on TJC, CMS, DNV, State, and best practices in meeting regulatory/accreditation requirements.

• Serve as system liaison to TJC, CMS, DNV, and the State in regulatory/accreditation matters.

• Provides review and guidance in development of system policies and procedures from a regulatory and safety perspective.

Requirements, Preferences and Experience

Registered Nurse required, MSN preferred

5-7 years Regulatory, accreditation, and quality improvement experience in a multi-hospital system.

CPHQ obtained within 1 year of hire required.

Current CPHQ certification desired

About Baptist Memorial Health Care

At Baptist, we owe our success to our colleagues, who have both technical expertise and a compassionate attitude. Every day they carry out Christ's three-fold ministry-healing, preaching and teaching. And, we reward their efforts with compensation and benefits packages that are highly competitive in the Mid-South health care community. For two consecutive years, Baptist has won a Best in Benefits award for offering the best benefit plans compared with their peer groups. Winners are chosen based on plan designs, premiums and the results of a Benefits Benchmarking Survey.

At Baptist, We Offer:

• Competitive salaries

• Paid vacation/time off

• Continuing education opportunities

• Generous retirement plan

• Health insurance, including dental and vision

• Sick leave

• Service awards

• Free parking

• Short-term disability

• Life insurance

• Health care and dependent care spending accounts

• Education assistance/continuing education

• Employee referral program

Job Summary:

Position: 9348 - System Manager-Quality & Accreditation RN

Facility: BMHCC Corporate Office

Department: HS Quality Corporate

Category: Quality, Compliance & Safety

Type: Non Clinical

Work Type: Full Time

Work Schedule: Days

Location: US:TN:Memphis

Located in the Memphis metro area REQNUMBER: 27512