Coffee Regional Medical Center

Quality Management & Accreditation Coordinator

POSITION SUMMARY

The Quality Management and Accreditation Coordinator is responsible for coordinating, implementing, and monitoring quality management activities to ensure compliance with regulatory, accrediting, and organizational standards. This role supports continuous quality improvement initiatives, prepares the organization for accreditation surveys and audits, and promotes patient safety, risk reduction, and performance excellence. The coordinator collaborates with interdisciplinary teams to maintain compliance, analyze quality data, and drive improvements aligned with best practices and accreditation requirements.

OVERVIEW

The Quality Management and Accreditation Coordinator is responsible for maintaining quality assurance and readiness for accreditation across the organization. By collaborating with leadership and staff across hospital departments, the coordinator helps maintain high-quality standards and achieve successful accreditation results.

QUALIFICATIONS

A. Knowledge, Skills, and Abilities

• Excellent customer service skills.

• Reads and understands the English language.

• Ability to think critically and analytically with little or no supervision.

• Ability to work effectively in situations of high stress and conflict and communicate goals and outcomes.

• Ability to process information and prioritize.

• Possesses exceptional verbal and written communication skills.

• Possesses independent work habits, is self-reliant and self-directed.

• Ability to learn, adapt, and change as required by the job functions.

• Ability to maintain absolute confidentiality of material and information accessed and reviewed.

• Basic computer literacy

• Ability to move freely, reach, bend, and complete light lifting.

• Ability to use good body mechanics while performing daily job functions and ability to follow specific OSHA guidelines.

• Ability to maintain attendance to meet standard job practices.

B. Education

• Associate or Bachelor's degree in Nursing required; BSN preferred

C. Licensure

• Current Registered Nurse (RN) license required.

D. Experience

• Minimum of two (2) years of experience as a Registered Nurse (RN) required

• Experience with accreditation surveys and performance improvement activities preferred.

E. Interpersonal skills

F. Essential technical/motor skills

G. Essential physical requirements

• Sedentary: Exert up to 10 lb. of force occasionally and/or a minute amount frequently - greater than 75%

H. Essential mental requirements

I. Essential sensory requirements

J. Other

• Computer proficiency and efficiency

• Able to independently and critically think, manipulate numbers, interpret and analyze data.

• Demonstrate the ability to make highly competent professional judgments and decisions.

K. Equipment used

OTHER QUALIFICATIONS

A. Exposure to hazards (body fluid exposure level)

• Level III

B. Age of Patient Populations Served

• No patient contact

JOB SPECIFIC DUTIES AND PERFORMANCE STANDARDS

• Below are those tasks, duties, and responsibilities that comprise the means of accomplishing the position’s purpose and objectives. These are critical or fundamental to the performance of the position. They are the major functions for which the person in the position is held accountable. The following are the essential functions of the position, along with the corresponding performance standards.

Major Task, Duties, and Responsibilities

Maintain readiness for accreditation and regulatory surveys; assist with survey preparation and follow-up.
Monitor compliance with accreditation standards, policies, and regulatory requirements.
Assist in tracer activities and mock surveys.
Monitor and interpret accreditation regulatory standards and updates, then communicate them to the appropriate managers.
Support development, review, and maintenance of policies, procedures, and clinical standards.
Collaborate with leadership and interdisciplinary teams to implement corrective actions and improvement plans.
Track and monitor Corrective Action Plans (CAP) to ensure timely completion and compliance.
Assist in monthly safety rounds.
Support the organization's quality management program and continuous improvement efforts.
Assist with investigation, tracking, and trending of quality concerns, incidents, and patient safety events.
Educate staff on quality, compliance, and accreditation requirements as needed.
Maintain communication and good working relationships with leadership, staff, and interdisciplinary teams.
Attend and actively participate in required committees related to quality, safety, and accreditation.
Assist the Quality department with other responsibilities as needed.

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