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Primary Responsibilities for Quality Hospital Accreditation:
Perform accreditation readiness activities for internal mock-surveys, and required accreditation activities. Responsible to facilitate a continuous readiness in collaboration with healthcare quality colleagues and management. Collaborate with an interdisciplinary team of healthcare professionals to ensure national measures and standards are being met. Facilitate the development, review, preparation, and implementation of accreditation readiness activities. Collaborate with management to maintain a written Quality Management Plan, along with related policies and procedures, consistent with the mission and vision of the organization and in compliance with the TJC and other regulatory agency standards. Direct the timely submission of patient care data for patient satisfaction and TJC. Analyzes findings and implements appropriate interventions to demonstrate improvements in quality outcomes and patient satisfaction. Manage databases, information, and other resources in order to provide necessary documentation and communication. Meet deadlines and be responsible to ensure communication / training of new standards and/or regulations that impact assigned functions and reporting systems to identified stakeholders. Work closely with the Quality Management leadership team. Maintain knowledge of accreditation, regulatory, licensing and other standards, requirements, and guidelines applicable to hospitals and hospital-based clinics, including but not limited to TJC, CMS, AHCA, Commission on Cancer, and professional nursing standards. Provide support and expertise to perform general functions for the department as requested, on an individual basis or as a team member, e.g., clinical database coordination, team/task force development and facilitation, maintenance of policies and procedures staff education, committee support, continuous accreditation preparedness, quality assurance, data collection and validation, chart review, medical staff peer review and credentialing, and OPPE and FPPE.
This list of duties and responsibilities is not intended to be all-inclusive and may be expanded to include other duties or responsibilities as necessary.
CORE QUALIFICATIONS
Education:
Minimum Bachelors Degree in Nursing, Health Science, Public Health, Health Informatics or a related health care field.
Certification and Licensing:
Minimum State of Florida Practical Nurse (LPN) or Registered Nurse (RN); or ability to obtain a Florida licensure by endorsement in first six months of position start date. Clinical licensure must be kept clear and active for duration of employment.
Basic Life Support (BLS)
Experience:
Minimum 1 year clinical nurse work experience in a clinical or healthcare environment with a Bachelors Degree.
Work experience needs to include at least 2 years direct experience working in Healthcare Quality, and a minimum of 6 months work experience inclusive of hospital accreditation.
Public speaking experience strongly preferred.
Proficiency with Microsoft Office Suite programs, Excel, PowerPoint, Word. Working knowledge of accreditation, regulatory, licensing and other standards, requirements, and guidelines applicable to hospitals and hospital-based clinics, including but not limited to TJC, CMS, AHCA, Commission on Cancer, and professional nursing standards.
Preference given to any combination of the following experiences:
- Coursework, continuing education completion of quality and patient safety, clinical informatics, patient centered outcomes, quality improvement, and related topics.
- Acute care experience within the last two years.
- National Certification in area of specialty.
- Familiar with aspects of care, standards of care metrics for accreditation and maintenance, and quality performance improvement.
- Experience with EpicCare EMR (EpicCare Ambulatory, Care Everywhere, MyUHealthChart, Workbench)
- Previous working experience with any of the following programs preferred: Sequel, ProDiver, Care Discovery, Tableau, NetAccess, Cerner, Sovera and/or Vizio
- Experience with spreadsheets and database software.
- Evidence of ability to draw on knowledge from the following areas: Measurement of patient needs and nursing workload, continuous process improvement processes, performance improvement, service excellence, systems for patient safety, healthcare quality.
- Knowledge of the principles and practices of value-based care, including familiarity with barriers to high-value care.
- Knowledge of the principles and practices of value-based decision-making, health care payment / reimbursement, and delivery models.
Knowledge, Skills and Behaviors:
- Commitment to University Values: Diversity, Integrity, Responsibility, Excellence, Compassion, Creativity, Teamwork.
- Excellent technical skills: Demonstrated competency in computer applications, inclusive of the ability to learn new applications and programs; excellent typing skills.
- Professionalism: Ability to incorporate national professional organization as well as business unit and health systems goals to improve patient safety and quality outcomes.
- Excellent interpersonal and presentation skills: Ability promote and sustain outstanding interpersonal and customer service skills (verbal and written) while accepting responsibility to ensure all working relationships are respectful and professional. Ability to collaboratively communicate critical guidelines and requirements to a broad range of clinicians and non-technical staff that obtain the desired results in a collegial manner.
- Excellent critical thinking skills: Ability to consistently apply independent and critical thinking skills to solve problems and escalate problems.
- Ability to be self-directed while successfully managing the prioritization and execution of multiple deadline-driven projects simultaneously.
- Excellent attention to detail: Demonstrated ability to accurately review, screen and enter data.
- Excellent communication and presentation skills: Ability to clearly, effectively, and respectfully communicate questions, ideas, and solutions verbally and in writing to a broad spectrum of specialized skill and clinical experience.
- Ability to conform to shifting priorities, demands, and timelines through analytical and problem solving capabilities
- Ability to ensure consistent and accurate adherence to established workflows and processes.
- Required ability to sustain mature judgement and maintain strict confidential information and patient confidentiality as mandated by HIPAA, and University policies, respect the rights and privacy of others at all times.
- Required to maintain current knowledge and practice in compliance with standards established by external regulatory agencies that impact job performance and deliverables, and maintain active licenses / certifications as deemed required by minimum requirements for position, e.g., maintain sufficient knowledge of healthcare quality programs and activities to ensure hospital and medical staff activities are in compliance with regulations.
The University of Miami offers competitive salaries and a comprehensive benefits package including medical, dental, tuition remission and more.
UHealth-University of Miami Health System, South Florida's only university-based health system, provides leading-edge patient care powered by the ground breaking research and medical education at the Miller School of Medicine. As an academic medical center, we are proud to serve South Florida, Latin America and the Caribbean. Our physicians represent more than 100 specialties and sub-specialties, and have more than one million patient encounters each year. Our tradition of excellence has earned worldwide recognition for outstanding teaching, research and patient care. We're the challenge you've been looking for.
The University of Miami is an Equal Opportunity Employer. Applicants and employees are protected from discrimination based on certain categories protected by Federal law.
Job Status:
Full timeEmployee Type:
Staff