1. Position Summary:

The Accreditation and DNV Program Manager is responsible for ensuring that the hospital maintains its specific accreditation programs in a state of continuous survey readiness. This includes the preparation, facilitation, and coordination of all DNV program-specific survey activities conducted by accrediting and governmental bodies within the organization. The manager will have comprehensive oversight of all DNV specialty programs, including ISO-9001, Stroke Center of Excellence, and Joint Center of Excellence. In the realm of ISO oversight, the manager will lead the organization’s Quality Management System (QMS), coordinating the efforts of various stakeholders to ensure ongoing compliance with established standards. The role involves close collaboration with board members and executives to secure their engagement and support for the QMS program on an annual basis. The Accreditation and DNV Program Manager will exercise independent judgment and decision-making, utilizing regulatory guidance to enhance compliance and improve patient outcomes. Key responsibilities include overseeing the hospital’s ISO Audit program, leading projects pertinent to the committee’s scope, and facilitating the implementation of corrective action plans for non-conformities in accordance with DNV standards. The manager will ensure that all corrective plans effectively measure, monitor, and analyze necessary data to foster improvement and sustainability. Additionally, the manager will collaborate with physicians and directors to conduct any DNV program gap analyses, ensuring all stakeholders are informed of regulatory changes and are actively working towards compliance with all requirements.

1. Qualifications:

A. Education:

• Must be currently Licensed in the state of Texas as a Registered Nurse.
• Bachelor’s degree in nursing required. Master’s degree in nursing or other healthcare related field preferred.
• Minimum of 1-2 years or experience in hospital-based or clinic-based performance improvement and knowledge of regulatory requirements (i.e., TJC, DNV, CIHQ CMS Core Measures, MIPS, CLIA/CAP, Meaningful Use, etc.) related to quality is required.

B. Training and Experience:

A minimum of two years’ experience preferred in organizational accreditation and licensure; at least five years’ experience preferred in a health-related discipline to include:

• Hospital structure, policies and procedures

Must obtain Lean Six Sigma Green Belt within one year (1) of hire.

1. Unusual Physical Demands and Working Conditions:

1. Potential for frequent interruptions.

1. Potential for extended periods of walking/standing as tracers/rounds are conducted.

1. Potential for stressful situations and long hours.