RN Quality and Accreditation Specialist- Full Time, Day Shift

Job Summary

 

The Quality and Accreditation Specialist is responsible for supporting hospital-wide initiatives that ensure compliance with regulatory and accreditation standards, promote continuous survey readiness, and advance performance improvement efforts. This position collaborates with leaders, clinical teams, and frontline staff to develop, implement, and sustain programs that enhance patient safety, quality of care, and operational excellence in alignment with the organization’s Quality Assessment and Performance Improvement (QAPI) Plan.

 

Essential Functions

 

- Monitors and interprets standards from The Joint Commission (TJC), Centers for Medicare and Medicaid (CMS), state, and other regulatory agencies.

- Coordinates and supports ongoing accreditation readiness activities, including mock surveys, tracers, and environment of care rounding.

- Partners with department leaders to develop and maintain policies, plans of correction, and evidence of standard compliance.

- Tracks and communicates regulatory updates, survey findings, and follow-up actions to ensure timely resolution.

- Assists departments with analysis of patient-safety events, trends, and improvement opportunities, and supports the development of patient-safety improvement plans.

- Facilitates and supports performance improvement teams using Lean, Six Sigma, and Plan-Do-Study-Act (PDSA) methodologies.

- Assists in the collection, analysis, and reporting of performance metrics, dashboards, and scorecards.

- Coordinates the development of department-specific and organizational QAPI initiatives and assists with data validation and outcome measurement.

- Educates staff and leaders on performance improvement tools and methodologies.

- Collaborates with clinical departments to identify trends and implement process improvements that enhance quality outcomes.

- Leads or participates in multidisciplinary rounding and tracers for continuous survey readiness.

- Develops and delivers education related to accreditation standards, QAPI principles, and quality reporting requirements.

- Serves as a liaison between hospital leadership and external accrediting bodies during surveys and site visits.

 

Other Duties

- Participates in departmental and association wide informational meetings and inservices, including staff meetings, association wide forums, and seminars.

- Reviews department and association wide policies and procedures annually. Develops and maintains new policies and procedures as needed.

 

Duties, responsibilities and activities may change or new ones may be assigned at any time with or without notice.

 

Abilities

- Strong knowledge of TJC standards, CMS Conditions of Participation and Arizona state regulatory requirements.

- Excellent analytical and critical thinking skills.

- Strong leadership, project management, and organizational abilities.

- Proficiency in data analysis, report preparation, and performance dashboards.

- Effective communication and facilitation skills with all levels of staff and leadership.

- Ability to manage multiple priorities in a fast-paced, deadline-driven environment.  

- Must read, write, speak, and understand English.

 

Supervisory Responsibilities

 

- None

 

Work Environment

 

At Summit Healthcare, our mission statement is that we are trusted to provide exceptional, compassionate care close to home. Our vision is to be the healthcare system of choice.

 

To uphold our mission and vision statements, we expect all employees to practice SHINE Behavioral standards:

- Always SHINE – show respect and be kind.

- Always work together – we are on the same team.

- Always serve others – no job is beneath you.

- Always maintain high standards of quality and safety – best practice every time.

- Always communicate clearly – be compassionate.

- Always practice integrity – maintain confidentiality.

- Always be accountable – take responsibility.

- Always empower – create an environment of success.

- Always excel – don’t settle for mediocrity.

- Always promote wellness – make choices for a healthy lifestyle.

 

Physical Demands

 

 

Exerts up to 20 lbs. of force occasionally, and/or up to 10 lbs. of force frequently, and/or a negligible amount of force constantly to move objects. Physical demands are in excess of those of Sedentary work. Light work usually requires walking or standing to a significant degree. Worker is exposed to extensive computer work.

 

Required Education and Experience

 

- Current Arizona Registered Nurse (RN) license in good standing.

- Certification in Certified Professional in Healthcare Quality (CPHQ), Lean Six Sigma or other accredited healthcare quality improvement certification within 12 months of hire.

- Bachelor’s Degree in Nursing (BSN).

- Minimum of 5 years of clinical experience in an acute care setting.

- Minimum of 3 years of clinical leadership experience or clinical professional required (e.g., charge nurse, team lead or supervisory role).

 

Preferred Education and Experience

 

- Master’s Degree in Nursing, Healthcare Administration, or related field preferred

- Minimum of 2 years in quality, regulatory compliance, or performance improvement role preferred.

 

OSHA Exposure Category:

 

Involves no regular exposure to blood, body fluids, or tissues, and tasks that involve exposure to blood, body fluids, or tissues and are not a condition of employment.

 

This is a safety sensitive position.