Registered Nurse (RN) - Manager
North Mississippi Health Services
West Point, MS

**JOB SUMMARY**

The Regional Accreditation Program  Manager for NMHS will Manages the regional accreditation program to include regulatory, performance improvement and overall high reliability practices while working collaboratively with the Regional Director.
 

 

**JOB** **FUNCTIONS**

Essential functions include:

*  Coordinate the regional quality management system to include accreditation, ISO certification, internal auditing and performance improvement
* Provides ongoing performance monitoring and action planning on key standardized quality andsafety metrics
* Collaborates with Regional Director to develop and implement standardized plans, processes, structures, strategies and internal auditing tools for planning and coordinating the daily operations of the regional Quality Department
* Manages regional standard processes and internal audits to ensure continual compliance with regulations and standards set forth by DNV and other accrediting bodies
* Coordinates a comprehensive program to improve patient outcomes and minimize patient harm through the implementation of processes and systems that support a consistent, standardized culture of quality and safety
* Coordinates performance improvement teams and provides project management and subject matter expertise for teams
* Leads continual survey readiness through internal auditing and other processes for compliance with standards set forth by DNV, ISO and other relevant regulatory and reporting agencies
* Provide regional expertise in application of KATA methodology to improve performance
* Participate in the scheduled review and evaluation of the regional quality, infection control, safety & performance improvement plan
* Establish regional partnerships with physicians, nurses, and team members across all area in efforts to enhance communication around Quality, Safety and Patient Experience related performance
* Serve as a regional point of contact for Quality and develop expertise and proficiency as a subject matter expert in quality and high reliability

Other Duties as Applicable:

*  Participates in other duties as identified by individual facility need
* Serve as a liaison to Medical staff departments for coordination of quality improvement actions involving patient care processes and physician processes
Works closely with Regional Director, Leadership Team, Medical Staff and Governing Board to implement strategies to promote patient safety, decrease risk and increase quality of care and outcomes.
Serves as regional liaison for accreditation and state surveysProvides leadership for Quality Assurance Performance Improvement (QAPI) Committee
* Serve as a regional point of contact for quality and develop expertise and proficiency as a subject matter expert in quality and safety related topics and high reliability.
* Coordinates with Regional Director to design and implement the performance improvement program
* Participates in development of clinical outcomes goals for North Mississippi Health Services
* Assures timely review of issues affecting clinical outcomes
* Reviews and ensures timely response to safety solutions
* Authorized to act in behalf of the organization in correcting deficiencies related to life and health


 

 

 

**QUALIFICATIONS**

 

 

 **Education**

 

 

**Education Level**

**Education Details**

**Required/Preferred**

 

 

Bachelor's Degree

Nursing

Required or


 

 

Associate's Degree

In lieu of Bachelor's Degree will accept Assoc degree
with 3 additional years beyond required experience

Required


 

 

Master's Degree

Master of Science in Nursing

Preferred

 

 


**Licenses and Certifications**
 

 

 

 

**Licenses and Certifications**

**Licenses and Certifications Details**

**Time Frame**

**Required/**
**Preferred**

 

 

 

Lean Certification

within 1 Year

Required

And

 

CPHQ - Certified Professional in Healthcare Quality

 

Upon Hire

Preferred

And

 

 

 

Upon Hire

Preferred

And

 

CPPS - Certified Professional in Patient Safety

 

Upon Hire

Preferred

 


**Work Experience**

 

 

 

 

**Number of Years**

**Work Experience Details**

**Required/**
**Preferred**

 

 

4-6 years

5 years - related experience such as PI methodology

Preferred

 

 


**Knowledge Skills and Abilities**
 

 

 

 

 

**Knowledge, Skills, Abilities**

**Required/Preferred**

**Proficiency**

 

Strong interpersonal and communication skills; excellent relationship skills to build teams and cross-campus and affiliate relationships - required

Selection Required

N/A

 

Strong problem solving, critical thinking, analytical and reasoning skills - required

Selection Required

N/A

 

Group facilitation and public speaking – preferred

Preferred

N/A

 

Proficient computer skills required

Selection Required

N/A

 

The scope of collaboration/coordination includes the work products / functions that includes Quality Standards, Patient Safety, Clinical Performance Improvement, Accreditation and Regulatory Readiness.

Selection Required

N/A

 

Works closely with Regional Director, Leadership Team, Medical Staff and Governing Board to implement strategies to promote patient safety, decrease risk and increase quality of care and outcomes.

Selection Required

N/A

 

Serves as regional liaison for accreditation and state surveys

Selection Required

N/A

 

Provides leadership for Quality Assurance Performance Improvement (QAPI) Committee

Selection Required

N/A

 

Must have the ability to initiate, establish and continually improve relationships with all staff to ensure their cooperation and participation in the performance improvement program.

Selection Required

N/A

 

Must convey a high degree of professionalism and confidentiality at all times.

Selection Required

N/A

 

Must be able to establish a network of partners both internally and externally to promote benchmarking and improvement opportunities

Selection Required

N/A

 

Works with Medical Staff Coordinator to present data, educate and update

Selection Required

N/A

 

Ability to comply with submission deadlines for inpatient and outpatient quality reporting

Selection Required

N/A

 

Ability to comply with regulatory guidelines

Selection Required

N/A

 

Ability to maintain a high level of accuracy in daily work

Selection Required

N/A

 

Stay abreast of changes, guidelines and regulations for all areas of responsibility

Selection Required

N/A

 

Utilize project management skills and tools to support performance improvement activities

Selection Required

N/A

 

Accountability

Selection Required

N/A

 

Serve as a regional point of contact for quality and develop expertise and proficiency as a subject matter expert in quality and safety related topics and high reliability.

Selection Required

N/A

 

Coordinates with Regional Director to design and implement the performance improvement program

Selection Required

N/A

 

Participates in development of clinical outcomes goals for North Mississippi Health Services

Selection Required

N/A

 

Ensures timely review of issues affecting clinical outcomes

Selection Required

N/A

 

Reviews and ensures timely response to safety solutions

Selection Required

N/A

 

Authorized to act in behalf of the organization in correcting deficiencies related to life and health

Selection Required

N/A

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 



**SCOPE**
**Freedom To Act:**
**Problem Solving:**
**Impact:**
**Financial Responsibility:**

* Sales Revenue Target Responsibility: 
* Approval Responsibility:
* P & L Responsibility:
* Assets Controlled:
* Controllable Expenses (e.g., Payroll and other budgeted items):
* Total Financial Responsibility:

**Budget Responsibility**

* Primary Budget Responsibility:
* Shared Budget Responsibility: