Manager Accreditation - Strategic Quality Performance

Lakeland Regional Health is a leading medical center located in Central Florida. With a legacy spanning over a century, we have been dedicated to serving our community with excellence in healthcare. As the only Level 2 Trauma center for Polk, Highlands, and Hardee counties, and the second busiest Emergency Department in the US, we are committed to providing high-quality care to our diverse patient population. Our facility is licensed for 910 beds and handles over 200,000 emergency room visits annually, along with 49,000 inpatient admissions, 21,000 surgical cases, 4,000 births, and 101,000 outpatient visits.

Lakeland Regional Health is currently seeking motivated individuals to join our team in various entry-level positions. Whether you're starting your career in healthcare or seeking new opportunities to make a difference, we have roles available across our primary and specialty clinics, urgent care centers, and upcoming standalone Emergency Department. With over 7,000 employees, Lakeland Regional Health offers a supportive work environment where you can thrive and grow professionally.

Responsible for planning and coordinating the hospital-wide Joint Commission continuous survey readiness program. Collaborates with the Patient Safety Officers to develop and implement a hospital-wide Joint Commission continuous survey readiness program and works with directors, physicians, managers and staff to facilitate activities to maintain compliance of accreditation standards as well as federal and state regulations. Other responsibilities include leading regular meetings with Joint Commission Chapter leaders to facilitate change. Lead, plan, and execute recurring mock surveys to assess compliance readiness. This person shall serve as a leader and educator regarding best practices to maintain regulatory and accreditation compliance. Maintains the current knowledge regarding accreditation and regulation information and shares that information with senior leaders, department managers and staff. Works closely with the Director and Patient Safety Officers to assure that all recommendations for improvement, resulting from Joint Commission surveys or AHCA visits, are implemented timely and that the appropriate documentation is submitted.

• Fosters an inclusive and engaged environment through teamwork and collaboration.
• Ensures patients and families have the best possible experiences across the continuum of care.
• Communicates appropriately with patients, families, team members, and our community in a manner that treasures all people as uniquely created.

• Behaves in a mindful manner focused on self, patient, visitor, and team safety.
• Demonstrates accountability and commitment to quality work.
• Participates actively in process improvement and adoption of standard work.

• Demonstrates responsible use of LRH's resources including people, finances, equipment and facilities.
• Knows and adheres to organizational and department policies and procedures.

People At The Heart Of All We Do

• Fosters an inclusive and engaged environment through teamwork and collaboration.
• Ensures patients and families have the best possible experiences across the continuum of care.
• Communicates appropriately with patients, families, team members, and our community in a manner that treasures all people as uniquely created.

• Behaves in a mindful manner focused on self, patient, visitor, and team safety.
• Demonstrates accountability and commitment to quality work.
• Participates actively in process improvement and adoption of standard work.

• Demonstrates responsible use of LRH's resources including people, finances, equipment and facilities.
• Knows and adheres to organizational and department policies and procedures.

• Collaborates with Director of Strategic Performance and Patient Safety Officers to develop and manage a hospital-wide Joint Commission continuous survey readiness program in order to assure safe patient care. Helps implement a plan to prepare for and ensure successful Joint Commission accreditation surveys. Helps ensure that recommendations for improvement resulting from Joint Commission surveys are completed thoroughly and timely
• Organizes, leads and implements the tracer methodology for standard of compliance: Joint Commission, CMS, ACHA and other regulatory bodies. Coordinates and schedules mock tracers throughout the organization at regular intervals.
• Leads accreditation activities such as Joint Commission Chapter Lead Meetings on a regular basis to facilitate changes and standard compliance. Follows up to ensure standard compliance maintenance.
• Maintains up to date knowledge of all standard and regulation revisions and provides continuous education for hospital and medical staff. The knowledge is obtained through self-training, formalized training and participation in national organizations.
• Documents and maintains data within TJC accreditation site in preparation for submission for annual updates and requirements
• Collaborates with Patient Safety Officers to assure activities necessary to evaluate LRH's compliance with the Joint Commission Sentinel Event Alerts.
Coordinates, aggregates, and reports data on patient safety and regulatory compliance to the committees, leadership and executive team.

Essential:

• Expert knowledge of Joint Commission standards and CMS Conditions of Participation
• Strong planning and organization, critical thinking and decision-making skills and leadership and coaching/staff development skills.
• High degree of confidentiality, maturity, tactfulness and business ethics.
• Strong written and verbal communications skills, coaching and mentoring skills, negotiation and conflict resolution skills.
• High degree of self-motivation, commitment and integrity.

• Good working knowledge of computer software programs for word processing, spreadsheet, database, graphics, and statistical tools
• Ability to transform data into information easily understood by others;
• Good analytical problem-solving skills.

Essential:

• Bachelor Degree

• Master Degree

Essential:

• BSN or other Healthcare License

• MBA, MSN, Masters Health Care Administration, other Master Programs relating to information management

Essential:

• Basic Cardiac Life Support

Other information:
Licenses Essential: RN or Healthcare License
Certifications Preferred: Certified Professional in Health Care Quality
Experience Essential: Minimum of five years in a technical/professional role with increasing leadership responsibility.
Five years healthcare experience with demonstrated success in leadership role.
Experience Preferred: Five years of experience with responsibility for conducting hospital-wide Joint Commission continuous survey readiness activities and preparing a hospital for a least one accreditation survey.