This position will oversee Accreditation and Regulatory Affairs for Duke Regional Hospital. Strong knowledge of Joint Commission and CMS regulations is highly preferred.
Contribute to the achievement of the DUHS mission through the development and leadership of performance improvement activities in the operational and/or clinical arenas. Assure continual compliance with regulations and accreditation standards through monitoring activities and the design and implementation of strategies to enhance compliance.
Plan activities aimed at improving the hospital's performance in operations or clinical quality. Identify opportunities for improved performance. Analyze data to identify adverse trends and/or undesirable performance. Utilize performance improvement techniques and methodologies. Serve as a project manager for interdisciplinary teams. Establish performance targets. Design and implement strategies for enhancing performance. Evaluate effectiveness of improvement strategy through sustained monitoring of performance. Contribute to the establishment of performance improvement priorities for departments, functional units and for the organization as a whole. Support organization's efforts to maintain compliance with regulations and accreditation standards. Monitor compliance through formal and informal processes. Recognize opportunities for improving compliance. Design and implement strategies for enhancing compliance. Evaluate effectiveness of improvement strategy through sustained monitoring of performance. Increase organizational understanding of performance improvement methodologies and principles and compliance through the support of and participation in formal and informal professional development activities. Serve as an expert resource on performance improvement and compliance as it relates to organizational role. Produce reports and presentations on performance improvement and compliance. Develop, maintains and enhances knowledge through orientation, self- evaluation and professional development. Responsibilities may include varying levels of strategic planning and human and fiscal resource management. Perform other related duties incidental to the work described herein.
Knowledge, Skills and Abilities
Effective written and verbal communication skills
Ability to communicate with customers/staff with diverse educational backgrounds
Analysis of data and processes for opportunities for improvement
Ability to manage numerous diverse projects simultaneously through effective priority setting, efficient use of time, organization Knowledge of accreditation standards and regulations related to health care
Attention to detail and accuracy
Education Bachelors degree in a business or health-related field is required.
Minimum of 5 years work experience, including 3 years of experience with significant responsibility for performance/ process improvement. Experience leading work teams required. Experience can be supplemented with Master's degree with a Masters being equivalent to two years of experience.
Degrees, Licensures, Certifications
RN, BSN (REQUIRED)
Internal Number: 4786
About Duke University Health System
Duke Regional Hospital has served Durham, Orange, Person, Granville and Alamance counties and the surrounding communities for nearly 40 years. With more than 1,900 employees, its focus is on providing outstanding medical care with compassionate, personalized service in a comfortable community hospital setting. Duke Regional Hospital has 369 inpatient beds and offers a comprehensive range of medical, surgical and diagnostic services, including orthopedics, weight-loss surgery, women's services, and heart and vascular services, and also offers care at the Duke Rehabilitation Institute and Davis Ambulatory Surgical Center. In fiscal year 2018, Duke Regional Hospital admitted 16,299 patients and had 165,953 outpatient visits in fiscal year 2017.
U.S. News & World Report ranked Duke Regional Hospital as #10 in North Carolina and #4 in the Raleigh-Durham area for 2018-19.
Duke Nursing Highlights:
Duke University Health System is designated as a Magnet® organization
Nurses from each hospital are consistently recognized each year as North Carolina’s Great 100 Nurses.
Duke University Health System was awarded the American Board of Nursing Specialties Award for Nurs...ing Certification Advocacy for being strong advocates of specialty nursing certification.
Duke University Health System has 6000 + registered nurses
Quality of Life: Living in the Triangle!