Career Center

Overview

GENERAL SUMMARY

Directs projects related to the development of accreditation and certification standards and survey methods for use by healthcare organizations in ongoing quality assessment and improvement activities. Provides clinical guidance and support for non-clinical staff within the department, division, and the Enterprise. Coordinates, analyzes, and communicates the results of development activities resulting from work groups, field engagements, and testing and evaluation activities. Serves as faculty for surveyor and other education programs. Represents the Joint Commission at speaking engagements and as a liaison to various professional organizations. Participates in and/or leads work groups for clinically oriented projects of moderate complexity or specific project components within larger projects as assigned.

Responsibilities

PRINCIPAL DUTIES AND RESPONSIBILITIES:

• Provides clinical guidance and support for divisional and enterprise wide initiatives. Reviews, analyzes, and synthesizes literature in specified clinical topic areas related to issues of quality and safety in the delivery of patient care. Based on this review and analysis applies their independent clinical judgement in the development of clinically focused standards and survey methods. Understands the clinical implications of the standards on both the delivery of patient care and impacts to healthcare organization work flow.
• Engages with experts in defined clinically or healthcare focused topic areas, identifies quality and safety issues in assigned topic areas, develops proposals and recommendations to inform standards and survey method development.
• Develops and defines project goals, activities and work plans for departmental initiatives. Defines project parameters and specifications and organizes related staff resources. Formulates creative and innovative approaches to accomplishing project objectives.
• Manages daily operations related to assigned projects which are often very large and complex.
• Monitors current projects to ensure that they are conducted in a highly professional manner. Acts independently and pro?actively to manage and resolve project?related problems as they arise. Leads both department and interdivisional workgroups/teams related to assigned projects.
• Participates in the development of standard operating procedures necessary for smooth project implementation and consistent project performance.
• The following responsibilities apply only if assigned to a Strategic Business Unit (SBU): Actively contributes to the successful achievement of SBU performance objectives through effective SBU team involvement and proactive communication and collaboration.
• Provides professional/technical guidance and consultation to other Joint Commission divisions and personnel as it relates to standards and survey methods activities, and associated data collection, analysis and reporting.
• Manages and actively contributes to the development and refinement of standards and survey methods and data collection instruments for assigned projects including but not limited to:
  • Coordinating activities to ensure timely project implementation and completion.
  • Maintaining and expanding knowledge base using available resources.
  • Offering unique and innovative approaches and alternatives in strategies.

• Initiates, coordinates, and participates in the dissemination of information related to standards and survey methods development and refinement activities through journal publications, presentations at national conferences, speaking engagements related to project activities and internal communication vehicles (e.g., Accreditation Program Newsletters, Journal on Quality Improvement, etc.

• Prepares and presents memoranda, position papers and ad hoc reports for the Board of Commissioners, advisory bodies and senior management concerning all aspects of the department's work. Represents the department at external professional forums and in a broad variety of internal cross-divisional activities.
• Assists in the development and administration of departmental budgets related to specific projects.
• Promotes and supports RPI departmental/divisional projects, uses RPI tools appropriate for project work and participates as an RPI team member or lead when assigned.
• Successfully completes NFRO training and conducts onsite surveys as a central office surveyor within 3 years of hire.INDTJC

Qualifications

KNOWLEDGE, PRACTICAL EXPERIENCE AND SPECIAL SKILLS REQUIRED:

• Registered Nurse with the level of knowledge equivalent to that ordinarily acquired through the completion of at least a master's degree in a related health care field plus previous progressive leadership role in a health care setting.
• Five to seven years' experience in healthcare. Neurology/Stroke, Medical-Surgical, or ICU experience preferred. Understanding of overall hospital operations with experience in multidisciplinary and cross-departmental teams desirable. This experience should include, but need not be limited to:

• Recent clinical experience in a healthcare setting
• Progressive management experience in a health care setting
• Project leadership and/or management
• Ability to demonstrate critical thinking skills
• Excellent written and verbal communication skills

• Interpersonal skills to effectively coordinate the work of other professionals and to interact with members of health care organizations.
• Experience working with professional associations, clinical experts, and task forces.
• Requires minimum amount of direction and possesses the ability to communicate to a varied audience.
• 10-15% travel required.

This job description is intended to describe the general nature and level of work performed by an employee assigned to this position. The description is not an exhaustive list of all duties, responsibilities, knowledge, skills and abilities, and working conditions associated with this position. All requirements are subject to possible modification due to business needs and/or reasonable accommodations for individuals with disabilities.