Management and Program Analyst

Accreditation Compliance Specialist

Develop processes to assess and validate compliance checklists applicable to The Joint Commission standards.

Analyze and provide accreditation compliance reports, executive summaries, and briefings to the executive staff.

Develop and implement the execution of facility-wide mock surveys and analyze the results to identify and mandate correction of vulnerabilities.

Manage the organization's preparation and report of significant findings related to patient care practices to the Quality Council, Medical Executive Committee (MSEC) and Executive Committee.

Provide critical support to the Chief Medical Officer to ensure the organization is operated in strict compliance with the Defense Health Agency regulations.

Ensure data is relevant and meets regulatory requirements for The Joint Commission and DoD compliance with Quality Improvement/Process Improvement program(s).

Advise department chiefs and other staff on findings of analysis and recommends methods for improving outcomes.

Serve as the Military Treatment Facility's senior technical expert for the Performance Improvement (PI) program.

Develop policies and governance to standardize Performance Improvement (PI) procedures and training across the command.

Facilitate performance improvement activities throughout the organization that includes the planning, developing, directing, organizing and evaluating of improvement initiatives and ongoing measures of organization performance.

Collaborate with Patient Safety Manager, Risk Manager, Safety Manager, Clinical Operations, Patient Experience/Satisfaction, and Department Chiefs through the strategic planning process to prioritize quality assessment and performance improvement.