Reporting to the Executive Director of Quality Performance Improvement, this role is responsible for compliance with Joint Commission, OSHA, FDA and Department of Public Health, and other regulatory agency requirements.

Responsibilities include coordination of TJC and other accrediting bodies disease-specific certification activities, including accreditation activities, program development and related education to ensure compliance with regulatory standards. Responsible for operational processes of concurrent retrospective data collection, data entry and analysis, and external submission of data within established deadlines. Also responsible for the generation of summary reports and ongoing communication with appropriate hospital and/or medical staff to identify, recommend and facilitate the implementation strategies for improvement. 

Job duties and responsibilities 

Maintains current knowledge of regulatory/accreditation requirements and best practice strategies and serves as an expert resource for clinical and medical staff.

Facilitates and communicates regulatory requirements and changes, hospital policies and procedures and safety guidelines.

Serves as a liaison and communicates with external agencies to which data is submitted.

Researches and implements new information technology for meeting data requirements and continuous quality improvement standards.

Handles highly sensitive and confidential information.

Handles special projects as assigned.

Attains all agreed upon goals and objectives within specified time frames as part of the organization's overall mission.

Attends all required quality/safety training programs and can describe his/her responsibilities related to general safety, department/service safety, job specific related hazards.

Ensures a safe patient care environment is maintained at all times; reviews environment for compliance with Joint Commission, OSHA, FDA and Department of Public Health, and other regulatory agency requirements.

In collaboration with the education department, prepares, maintains and audits education records and leads education and outreach education required of disease specific certification.

Provides disease specific screenings and provides education and support within the community.

Prepares and updates patient education materials as needed.

Assists in the oversight of Quality, Safety, and Process Improvement program.

Minimum Education

Graduate of an associate's Program in Nursing- Required

Bachelor's Degree - Preferred

Minimum Work Experience

Three years of relevant progressive work experience in clinical healthcare preferred, including a minimum of one year direct experience in performance improvement. Working knowledge of federal, state and regulatory requirements in performance improvement, accreditation and licensure

License(s) / Certification(s)

Valid Registered Nurse (RN) license in the state of Georgia

Knowledge, Skill, and Abilities

Requires critical thinking skills, decisive judgment and the ability to work with minimal supervision. must be able to work in a stressful environment and take appropriate action.  

About St. Francis-Emory Healthcare

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