Joint Commission Accreditation Manager

VHA Inc. is a health care provider alliance of more than 2,200 not-for-profit health care organizations. We help members deliver safe, effective and cost-efficient care. VHA has 18 regional offices in 48 states as well as an office in Washington D.C.
Founded in 1977, we are dedicated to the success of not-for-profit, community-based health care. To help our members meet the needs of their communities, our mission is to improve members’ clinical and economic performance. We deliver on our mission by providing industry-leading supply chain management services and facilitating the development of member networks to drive sustainable results.

VHA (002799, Zone 4)

Internal employees must apply via internal job application on @work
Zone: 4
Contact: Paul Dao x6875


JOINT COMMISSION ACCREDITATION MANAGER

Location: Virtual Office - Eastern US

Will provide comprehensive on-site assessment to hospitals and health care systems on the Joint Commission standards and National Patient Safety Goals encompassing the complex integration of clinical, and cultural performance as well as plant/facilities management. Facilitate and provides implementation strategies and support to assure compliance and successful Joint Commission Accreditation. Educate organizational leaders, including senior hospital executives, staff and VHA regions on Joint Commission survey process, accreditation rules and policies, standards interpretation and strategies and tactics for compliance.

Conduct assessments on compliance with the Joint Commission standards and elements of performance encompassing Patient Safety, Ethics, Rights, and Responsibilities, Provision of Care, Treatment, and Services, Medication Management, Surveillance, Prevention, and Control of Infection, Improving Organizational Performance, Leadership, Management of the Environment of Care ( Fire Safety, Medical Equipment, Hazardous Materials Management, Utilities Management, Emergency Management, Safety and Security), Management of Human Resources, Management of Information, Medical Staff, and Nursing Leadership and structure. Interview senior executives o f HCO, direct care provider interviews including medical staff, nurses, and ancillary support staff, patient care observation, review of policies and procedures, review of medical staff bylaws, rules and regulations, medical staff performance data and creditialing processes, medical record review, and organizational structure and communication models.
Provide guidance in translating assessment information into the Joint Commission's Periodic Performance Review process to assure appropriate interpretation of the standards and validate HCO action plans when indicated.
Provide education on all of the Joint Commission standards outlined above including focus areas such as restraint use, medication management, patient safety, and performance improvement tools such as root cause analysis, and failure modes and effects analysis. Provides cross-references for other regulatory agencies or accrediting bodies such as CMS.
Write reports of assessment findings and recommendations for standards compliance. Research and integrates best practices into standard compliance recommendations. On team consultations, integrates findings of other team members into a comprehensive report.
Provide assistance and strategies to implement standards compliance initiatives. Provide recommendations and direction for correcting Joint Commission survey requirements for improvement. Review HCO action plans and measures of succes prior to submission to the Joint Commission to assure acceptance of the plan by the Joint Commission.
Provide onsite support during actual Joint Commission accreditation surveys. Survey support includes liaison responsibility between the HCO and Joint Commission survey team.
REQUIREMENTS
Bachelor's in Nursing, Quality Management, or Health Care Administration preferred. Experience with Joint Commission Disease Specific certification preparation preferred.
Registered nurse/RN licensure required. At least 7-10 years healthcare experience with 5+ years in clinical nursing. At least 3 years management or leadership experience. Must have mimimum 3 years experience of successful Joint Commission preparation leadership or Joint Commission surveyor experience.