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Duke University Health System Job Description


DUHS

DIR, ACCREDITATION & PATIENT SAFETY, PDC


Job Title: DIR, ACCREDITATION & PATIENT SAFETY, PDC
Job Code: 5139
FLSA: E
Job Level: G1
Revised Date: 10/01/2005
Supervisory Responsibility: Yes

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General Description of the Job Class

Direct and coordinate accreditation, policy and regulatory affairs initiatives for the Private Diagnostic Clinic (PDC); serve as the organizations liaison with JCAHO and other regulatory agencies focused on clinical care and patient safety.

 

Duties and Responsibilities of this Level

Provide overall direction necessary to ensure that clinical services are provided in accordance with standards established through state and federal regulations and JCAHO accreditation standards.

Provide administrative direction and support through collaboration with entity leadership and staff for activities related to accreditation and regulatory affairs, patient safety and performance improvement.

Serve as the organizational liaison with the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO). Serve as an expert resource on accreditation and regulatory issues to clinic staff and physicians.

Determine fiscal requirements and prepare budgetary recommendations; monitor, verify and reconcile expenditure of budgeted funds.

Develop and evaluate the goals of the Office and prioritize the work of the Office in accordance with the strategic objectives of the PDC.

Analyze clinic and medical center policy for internal consistency and compliance; ensure optimal clinical compliance with accreditation requirements. Analyze compliance with accreditation standards and clinic policies through the evaluation of information.

Communicate requirements and standards in a timely manner to the leadership of the PDC. Translate standards, requirements and policies into terms or processes meaningful to the target clinic, department, or facility.

Direct formulation of responses to accreditation findings and inquiries.

Provide consultation to relevant task forces, quality action teams and committees to insure ongoing compliance with standards.

Perform other related duties incidental to the work described herein.

 

Required Qualifications at this Level

Education:

Work requires a Bachelors degree in health administration or a health-related field. Knowledge of accreditation standards and/or policy formulation is preferred. Excellent organizational, oral and written communication skills, problem solving, program development, computer skills, strong leadership, and team building skills.

 

Experience:

Five years experience in a hospital, clinic or health-related setting. Administrative and clinical experience is preferred. Experience with analysis of accreditation standards and policies required.

 

Degrees, Licensure, and/or Certification:

N/A

 

Knowledge, Skills, and Abilities:

Knowledge of accreditation standards and/or policy formulation is preferred. Excellent organizational, oral and written communication skills, problem solving, program development, computer skills, strong leadership, and team building skills.

 

Distinguishing Characteristics of this Level

N/A

 

The intent of this job description is to provide a representative and level of the types of duties and responsibilities that will be required of positions given this title and shall not be construed as a declaration of the total of the specific duties and responsibilities of any particular position. Employees may be directed to perform job-related tasks other than those specifically presented in this description.


Essential Physical Job Functions

Certain jobs at Duke University and Duke University Health System may include essential job functions that require specific physical and/or mental abilities. Additional information and provision for requests for reasonable accommodation will be provided by each hiring department.