The Accreditation Program Manager is a registered professional nurse who is accountable to the Quality Management Officer (QMO). In collaboration with QSV staff, assumes accountability for the day to day oversight, coordination, implementation, and evaluation of all facets of accreditation readiness within the MVAHCS. The Program Manager works with individuals/services/leadership to prepare and obtain the information necessary for JCAHO and other accreditation/validation surveys.
The Accreditation Program Manager is responsible for translating standards, policies, directives, theories, and strategies into action within the complex interrelationships that exist related to external accreditation/review. He/she is responsible for maintaining clear communication between the facility and external accreditation/review bodies both to communicate relevant external accreditation/review information and to understand changes and potential impact on the facility and proactively recommend/implement corrective actions. Accrediting bodies and review groups in the purview of his/her responsibilities include, but are not limited to, Joint Commission, Office of Inspector General, VISN 23, Long-term Care Institute (LTCI), Laboratory College of American Pathologists (CAP), Commission for Accreditation of rehabilitation facilities (CARF).
Bachelor's prepared in Nursing required Master's preparation in Nursing or related field preferred Minimum of 3-5 years of professional nursing experience and previous accreditation experience CPHQ preferred
Key competencies include: Demonstrated professional, leadership, and organizational skills Demonstrated continuous improvement and critical thinking skills Demonstrated understanding of readiness principles for accreditation, associated regulatory requirements, and Joint Commission Standards and Elements of Performance Quality metric data collection and process improvement techniques Demonstrated data management skills and experience with EXCEL, MS PPT, and MS Word
Additional Salary Information: A recruitment/relocation incentive has been pre-approved and may be available.
Internal Number: 1
About Minneapolis VA Healthcare System
The Minneapolis VA Health Care System is an employer of choice! Our facility ranks #6 in the nation for veteran care. It is located in the Twin Cities between Minneapolis and St Paul. 3500 staff are employed, including 1300 nursing staff. The team oriented Quality Safety Values Department has 28 employees.
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