Under the direct supervision of the Supervisor, is responsible for participating in the processes involved in the commitment and system development of accreditation and certification readiness across the continuum of care at DHR. The Coordinator is responsible for participating in short term and long term strategies to ensure the organization’s vision, mission and values are carried out through the delivery of high quality cost effective patient care for the accreditation service line with a high level of integrity. POSITION EDUCATION/ QUALIFICATIONS :
Graduate of an accredited Vocational School of Nursing.
Current license as an LVN in the State of Texas.
Valid and current Driver’s License Required
Valid and current proof of Auto Insurance required.
Computer skills required with knowledge of Microsoft Office suite.
Good written and verbal communication skills required.
Some evening or weekend may be required
Bilingual – English/Spanish preferred
Strong organizational, interpersonal, management and leadership skills.
Proactive, self-confident and recognized as a credible resource in patient care and patient safety issues.
Ability to work independently, have good judgment, and decision making ability. JOB KNOWLEDGE/EXPERIENCE :
Minimum experience of three (3) years of accreditation/quality experience in a hospital setting preferred
Experience with coordinating TJC preparation and participation in State and CMS surveys within the last three years preferred.

POSITION RESPONSIBILITES:
Work collaboratively with patient care service staff and physicians to lead transformational change.
Ability to bring together diverse entities and personalities for the purpose of creating a highly effective and productive team. Knowledge of statistics, data collection and survey design.
Knowledge of State, Federal, and The Joint Commission regulations.
Willingness to learn additional accreditation and/or certification designations
Promotes the facility mission, vision and values by effectively communicating them to others. Considers mission, vision and values in developing services, standards and practices.
Establishes and enforces policies, procedures, standards and objectives.
Assist with planning and implementing the performance improvement program to meet the needs of the hospital and accrediation programs.
Provides education to medical staff, hospital staff and Governing Body around accreditation initiatives.
Assists with performance improvement activities and process improvement activities throughout the hospital.
Acts as resource person to administrative team, department managers and medical staff.
Assists department managers with preparation for various committee presentations.
Assist team with all regulator body surveys, i.e., TJC, State Licensing Review, HCFA (CMS) Validation surveys.
Ability to develop and analyze quality/performance data to identify trends, develop action plans, and implement program modification for change.
Must have a good understanding of regulatory standards/requirements. Coordinate the quality improvement and patient safety programs at DHR.
Must have a reliable method of transportation to travel to and from other units of the hospital as assigned. Other duties as assigned. Other information: LINES OF REPSONSIBILITES : (Chain-of-command) 1. LVN Accreditation Readiness Coordinator →2. Accreditation Readiness Supervisor → 3. Director of Accreditation Readiness and Patient Safety → 4. VP of Quality, Safety & Accreditation → 5. Physician Executive CUSTOMER SERVICE: Provide excellent customer service to all DHR customers. All employees are required to attend the DHR C.A.R.E.S program which outlines the Customer Service Principals including: Commitment, Accountability, Respect, Excellence and Service. AGE SPECIFIC : Employees must be able to demonstrate the knowledge and skills necessary to provide care appropriate to the age of the patients served in his/her assigned unit. The individual must demonstrate knowledge of principles of growth and development over the life span and possess the ability to assess data reflective of the patient’s status and interpret the appropriate information needed to identify each patient’s requirement relative to his or her age. AMERICANS WITH DISABILITIES ACT: (ADA) : A.

Indicated by bold print within performance standards, preceding individual numbered criteria. The following table provides physical requirements that will be associated with, but not limited to, this position:
Light/moderate lifting up to 20 lbs, from the floor to shoulder height.
Yes
Kneeling
Yes
Must be able to assist other employees with lifting more than 20 lbs.
Yes
Walking
Yes
Light/moderate carrying up to 20 lbs.
Yes
Standing/Squatting
Yes
Straight pulling
Yes
Sitting
Yes
Pulling hand over hand
Yes
Pushing
Yes
Repeated bending
Yes
Stooping/Bending
Yes
Reaching above shoulder
Yes
Climbing Stairs
Yes
Simple grasping
Yes
Climbing Ladders
No
Dual simultaneous grasping
Yes
Depth Perceptions needed
Yes
Ability to see
Yes
Identify Colors
Yes
Operating office equipment
Yes
Twisting
Yes
Operating mechanical equipment
Yes
Crawling
No
Ability to read and write
Yes
Ability to Count
Yes
Ability to hear verbal communication without aid
Yes
Operating Personal Vehicle
Yes
Ability to comprehend written/verbal communication
Yes
Other: Ability to deal with stress
Yes
OSHA Category
III
B. Working Conditions : The individual spends over 95% of his/her time in an air-conditioned environment with varying exposures to noise. There is protection from weather conditions but not necessarily from temperature changes. The position does have low exposure to malodorous, infectious body fluids from patients and some minimal exposure to noxious smells from cleansing agents. C. Occupational Exposure: This position has minimal to no exposure to blood, body fluids, or tissues and is an OSHA Category III (although situations can be imagined or hypothesized under which anyone, anywhere, might encounter potential exposure to body fluids). Person who performs these duties are not called upon as part of their employment to perform or assist in emergency medical care or first aid or to be potentially exposed in some other way. D. Aptitudes : HIGH 1 2 3 4 5 6 LOW Intelligence: General learning ability: The ability to “catch on” or understand instructions and underlying principles. Ability to reason and make judgments. 3 Verbal: Ability to understand meanings of words and ideas associated with them, and to use them effectively. To comprehend language, to understand relationships between words, and to understand meanings of whole sentences and paragraphs. To present information or ideas clearly. 3 Numerical: Ability to perform arithmetic operations quickly and accurately. 2 Spatial: Ability to comprehend forms in space and understands relationships of plane and solid objects. Frequently described as the ability to “visualize” objects or two or three dimensions, or to think visually of geometric forms. 2 Form Perception: Ability to perceive pertinent details and objects or in pictorial or graphic material to make visual comparisons and discriminations and see slight differences in shapes and shadings of figures and widths and lengths of lines. 3 Clerical Perception: Ability to receive pertinent details and verbal or tabular material. To observe differences in copy, to proofread words and numbers, and to avoid perceptual errors in arithmetic computation. 2 Motor Coordination: Ability to coordinate eyes and hands to fingers rapidly and accurately in making precise movements with speed. Ability to make a movement response accurately and quickly. 3 Finger Dexterity: Ability to move hands easily and skillfully. To work with fingers in placing and turning motions. 3 Manual Dexterity: Ability to move hands easily and skillfully. To work with hands in placing and turning motions. 3 Eye-Hand-Foot Coordination: Ability to move the hand and foot coordinately with each other in accordance with visual stimuli. 3 Color Discrimination: Ability to perceive and respond to similarities or differences in colors, shapes, or other values of the same or different color. To identify a particular color, or to recognize harmonious or contrasting color combinations, or to match color adequately. 3 I have read and reviewed my job description with my supervisor or designee and I understand the job I am expected to perform. If applicable ____________ certification will be completed within _________ time frame of hire/transfer date. Employee Signature: ________________________________ Date: ____________________ Transfer/Hire Date Effective: ________________________.

LVN Accreditation Readiness Coordinator - FT - Days -Accreditation Readi

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