AVP of Accreditation and Patient Safety
Summary:
Responsible and accountable for system compliance with regulatory requirements.
Directs, administers, and coordinates the system wide regulatory readiness for Virtua and its functional divisions.
Responsible for Virtua's knowledge and understanding of regulatory requirements and related survey activities.
Develops and implements strategies and initiatives to ensure that the System remains in a constant state of readiness for accreditation activities as well as various administrative projects as assigned.
Virtua's internal expert on regulatory/accreditation standards and regulatory/accreditation process.
Responsible and accountable for oversight and strategic direction of patient safety program for Virtua.
Leads patient safety initiatives, working in collaboration with leaders across the system towards process improvement, and risk identification and reduction, to support reduction of medical and health care errors, and other factors that contribute to unintended adverse patient outcomes.
Develops strategic and operational plans that build upon present patient safety program, to ensure that patient safety practices are evidence based and align with organizational goals.
Position
Responsibilities:
o Provides significant input and advice to Senior leaders in the positioning of regulatory readiness from a strategic perspective.
From an accreditation perspective, Virtua is considered a large, complex organization.
There are options and choice for approach and significant thought to be given to how it is accomplished.
o Responsible for collaboration with all System stakeholders in order to drive continual readiness and preparation activities for hospital services.
Provides education and facilitation of new standards.
Advises post-acute, behavioral health services and physician services.
Serves as internal expert for regulatory compliance including NJ State Department of Health Regulations, CMS Conditions of Participation and Joint Commission.
o Partners with AVP of Safety and Security for matters relating to Life Safety regulatory requirements.
o Identifies, analyzes, and monitors patient safety issues for the organization.
Responsible for implementing systematic approaches to achieve expected outcomes.
o Facilitates system safety strategy team in collaboration with leaders across Virtua.
o Responsible for the development of communication strategies to report on improving performance, accreditation, safety, and outcome information to key constituents and partners.
o Oversees development and implementation of error prevention techniques.
oCo-Chair of the Patient Safety Committee and plays a key role in patient safety initiatives promoting a culture that emphasizes safety in all aspects of its operations.
o May lead or serve a signification role in policy development, improvement teams, and audits.
o Builds genuine and credible relationships with all key constituents and collaborates on the development and implementation of strategic plans and related initiatives to reduce risk and harm to patients and employees.
o Interacts with customer groups (board, leadership, physicians, employees, and community) to foster partnerships to achieve desired quality and safety outcomes.
o Services as Virtua's primary liaison to Joint Commission.
Assists and advises divisions with linkages to Department of Health and other external regulatory bodies.
Performs all correspondence and filing of annual periodic performance reviews, requirement for improvement filing, data submission, application submission, response to complaints, etc.
following Joint Commission Processes and staying within the appropriate timeframes.
Position Qualifications Required / Experience Required:
Minimum of 7-10 years experience in regulatory/accreditation/patient safety.
Must understand systems thinking and be fluent in the use of performance improvement tools and techniques.
Possess knowledge of TJC and other regulatory standards and their application across the Virtua continuum of care.
Must have good skills using a PC (Word required, PowerPoint, and Excel required).
Must possess excellent verbal and written communication skills.
Demonstrate effective presentation skills and ability to lead meetings.
Must have broad-based knowledge of administrative practices, management principles, hospital/health system operations and program development.
Required Education:
Master's degree in health care field required.
RN PreferredTraining/Certifications/Licensure:
CPPS is preferred.
Yellow Belt and Coach trained to facilitate Workouts.
Salary:
$26.
67 - $37.
33.
Estimated Salary: $20 to $28 per hour based on qualifications.
|
|
 | |
