Accreditation Coordinator BSN at AdventHealth

Date Posted: 2/24/2021

Job Snapshot

  • Job Schedule
  • Date Posted:
  • Job ID:
  • Job Family
    Quality/Clinical Effectiveness
  • Travel
  • Shift
    1 - Day

Job Description


Accreditation Coordinator AdventHealth Shawnee Mission

Location Address: 9100 W. 74th Street, Shawnee Mission, KS 66204

Top Reasons To Work At AdventHealth Shawnee Mission

  • Providing faith-based, whole person care to Kansas City since 1962
  • Excellent health benefits, an onsite child care center and fitness facility  
  • Tuition reimbursement to support continuing education
  • Employee Referral Program
  • Largest health care provider in Johnson County with three campuses

Work Hours/Shift:

Full Time, Days

You Will Be Responsible For:
Department Core Competencies
  • Utilizes the Performance Improvement Model 
  • Utilizes excellent interpersonal skills to deal with challenging situations while maintaining strong supportive relationships. 
  • Readily available for questions; handles requests in a courteous and respectful manner. 
  • Communicates effectively, both written and verbally.
  • Demonstrates a proactive attitude and seeks to remedy situations before mistakes are made or corrects errors when found; takes responsibility for the overall quality image of the department.
  • Ensures accuracy of data collection and submission; validates integrity of data collected.
  • Develops data reports for projects, committees, hospital departments, medical staff departments, as designated.
  • Knowledge of and utilizes statistical approaches, measurement techniques, including benchmark and comparative data to develop quality reports.
  • Collects, aggregates, analyzes, summarizes and reports quality data for hospital organizational performance and physician performance data as indicates.  
  • Participates in hospital-wide outcomes and quality improvement initiatives/ performance improvement teams.
  • Assists in efforts to improve and streamline the process and workflow of the department.
  • Demonstrates the ability to set appropriate priorities. 
  • Recognizes how absence impacts the functioning of the healthcare team and strives to minimize this effect.
  • When requested, is willing to adjust personal schedule in order to complete workload when necessary
  •  Attends educational offerings as needed to promote continuous learning and support to department

Position Core Competencies

  • Responsible for staying current on CMS Conditions of Participation (CoP) and Joint Commission standards for all levels of care.
  • Responsible for Joint Commission Accreditation/CMS CoP Compliance
  • Ensures continuous survey readiness/compliance with accreditation standards.
  • Conducts or coordinates MOCK surveys, tracers, rounding, compliance audits, 
  • Conducts and abstracts chart audits of documentation e.g. clinical pertinence for the medical staff, open records reviews, critical test results, etc. 
  • Conduct Focused Standard Assessment for accredited programs
  • Communicates with and educates associates and medical staff on Joint Commission standards
  • Facilitates and coordinates changes necessary to remain compliant-"ever ready activities"
  • Responsible for on-site survey activities (preparation, planning, coordinating, etc.)
  • Serves as a liaison between AHSM's accredited programs and the Joint Commission
  • Communicates and facilitates necessary changes in order to remain continuously compliant with accreditation standards.
  • Collaborates with other hospital leaders in developing, monitoring, reporting and analyzing accreditation efforts.
  • Proactively seeks opportunities/mechanisms aimed at continually improving patient care, processes and compliance. 
  • Recommends and facilitates change to improve based on identified risks.
  • Facilitates the creation of an effective action plan in response to identified issues.
  • Responsible for follow through and oversight for completion and actions plans relating to identified issues, including follow up measures of effectiveness.
  • Working knowledge of Kansas Risk Management statutes, and Patient Safety Organization (PSO) requirements, as it pertains to patient safety and quality.
  • Completes accurate and timely collection of data  related to regulatory compliance.

What Will You Need?

  • Minimum 2-5 years of clinical nursing experience
  • BSN
  • Registered Nurse licensed in the state of Kansas
  • Microsoft Word and Excel, Windows, typing/word processing

Job Summary:
The Accreditation Coordinator is a part of the Quality Management team and reports to the Accreditation and Patient Safety Manager.  The Accreditation Coordinator works collaboratively with the Accreditation and Patient Safety Manager ensuring Joint Commission standards and CMS Conditions of Participation compliance.  Responsible for Joint Commission continuous readiness for the Hospital, Home Care, Behavioral Health, Shawnee Mission Surgery Center and Prairie Star Surgery Center Accreditations.  Also serves as a resource for hospital identified programs seeking Joint Commission Certification and other Accreditations.  

This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances.

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