Accreditation Coordinator- Quality Improvement
CHRISTUS Good Shepherd
GSMC - Longview-15500
700 E. Marshall Ave.
Longview, TX 75601
*Serve as a resource for interpretation of regulatory, accreditation and disease-specific care certification standards (as applicable) to include CMS, State, and TJC for Marshall, Longview, and Ambulatory Clinics.
* Interpretation of relevance of standards in relation to hospital/department policies and practices.
* Performs concurrent and closed medical record review audits to assist in determining compliance with accreditation and regulatory requirements.
.* Conducts patient and system tracers in patient care areas through observation of practice.
* Collects, analyzes and reports data in support of continuous readiness activities.
* Disseminates the results of audits and surveillance results as needed.
* Assist in assuring accuracy and timeliness in submission of corrective action plans to internal stakeholders and external agencies.
*Designs and implements survey management plans
*Develops and delivers staff and leadership education related to regulatory and accreditation standards and processes.
*Facilitates monthly Accreditation Readiness Committee to include agenda planning, minutes, presentations as needed.