Responsible for providing effective leadership and program direction to the Accreditation section of Quality Programs & Accreditation Department. Oversee the development, coordination, operations and integration of the Texas State Maternal Care and Neonatal ICU Care Programs for Harris Health System. Act as regulatory information resource for committees and departments. Works with all Medical Staff, Nursing, Allied Health and Support Services to ensure care delivery processes are in compliance with federal and state regulations. Ensures that the organization is in compliance with the State of Texas Maternal and Neonatal ICU designation requirement at all times. Participates in internal quality audit activities, leads performance improvement projects as results of survey findings. Possess leadership skills in a diverse work setting and able to perform variety of functions. Serve as a change agent.
Education/Specialized Training/Licensure: Bachelor's Degree in Nursing and Allied Health required Master's Degree in Healthcare Administration or Business Administration preferred
Licenses & Certifications Certified in Hospital Quality (CPHQ) Quality Auditor (ASQ CQA) Six Sigma preferred
5 years of experience in hospital related quality assessment, performance improvement program and development and accreditation and regulatory affairs.
3 years of experience in project management preferably in clinical and hospital settings
OTHER SPECIAL REQUIREMENTS: Working knowledge of externally mandated Quality Programs & Accreditation requirements (state and federal; TJC, DNV GL, ISO 9001:2015 other regulatory and licensing agencies etc).
Equipment Operated: Personal Computer, Fax Machine, Xerox Machine, Window Based Program (i.e. MS Word, Excel, etc).
Internal Number: 147407
About Harris Health System
The Harris Health System is a fully integrated healthcare system that cares for all residents of Harris County, Texas. We are the first accredited healthcare institution in Harris County to be designated by the National Committee for Quality Assurance as a Patient-Centered Medical Home, and are one of the largest systems in the country to achieve the quality standard. Our system includes 23 community health centers, five school-based clinics, a dental center and dialysis center, mobile health units, a rehabilitation and specialty hospital and two full-service hospitals.Ben Taub Hospital is a world renowned Level I Trauma Center with 586 licensed acute-care beds and provides a wide range of specialty care outpatient services. Lyndon B. Johnson Hospital is a 328 licensed bed acute-care hospital with a newly expanded Level III trauma center and a distinguished regional center for neonatal intensive care for high-risk deliveries.Harris Health is a teaching system for Baylor College of Medicine and The University of Texas Health Science Center at Houston (UTHealth). We train the next generation of healthcare providers on the latest medical procedures and technological breakthroughs.With... our fully integrated electronic medical records system, we offer patients the convenience and assurance that their medical history is accurate, safe and available when and where it is needed. Our Medical Home designation ensures that we offer a full range of preventive, specialty and acute care services for the entire family.