GENERAL SUMMARY:

Under limited direction, plans, organizes and maintains a process to ensure organizational compliance with regulatory standards and continuous survey readiness. Serves as an internal consultant for the interpretation of standards and functional measurement of compliance. Develops performance improvement plans with management/staff on an as needed basis. Interprets new regulations for education purposes and implementation efforts.

EDUCATION AND EXPERIENCE: 

Bachelors degree in Nursing or healthcare related field required , Masters degree in health care field preferred; RN preferred.

Minimum 5 years hospital experience required; clinical/operational experience preferred.

Demonstrated knowledge of TJC, DNV, CMS Conditions of Participation required and familiarity with other accrediting, licensing and regulatory standards desirable. 

Evidence of continuing education in standards/regulations/training QI/PI Team member, lead or facilitator 1 - 3 years required Scope: Broad Business unit/multidisciplinary team experience (working with several departments, and//or deep experience within one service line, value stream, etc).

Experience presenting to departmental, product line, and business unit leadership. 

Knowledge of current healthcare issues and trends.  

Proficient in Excel and Power Point. 

Organization skills. 

Strong relationship building and communication skills.

Additional Information Organization: Henry Ford Macomb Hospital Department: Perform Excellence & Qual-HFMH Shift: Day Job Union Code: Not Applicable