Reviews all Continual Survey Readiness (CSR) efforts for the department of Hematology/Oncology and BMT. Promotes a standard and effective approach to ensure the Oncology department is continually ready for an accreditation survey. Creates a culture of CSR at all levels and locations of NCHS.
Minimum Job Requirements
- Bachelor's Degree in Healthcare related field
- 2-4 years of experience with at least two nationally recognized accreditation surveys ( I.E. FACT, DNV, American College of Surgeons).
- 2-4 years of experience in quality assurance
Knowledge, Skills, and Abilities
- Masters in healthcare related field preferred.
- Experience in quality/performance improvement preferred.
- Excellent written and oral skills.
- Ability to establish a positive working relationship and rapport with medical staff, other department heads, staff, and colleagues.
- Ability to prioritize, work independently, and evaluate workload in order to meet deadlines.
- Ability to create reports using Microsoft Office.
- Ability to navigate the EMR.
- Ability to conduct quality review and develop action plans.
- Ability to maintain documentation for regulatory compliance.
- Reacts effectively to unplanned circumstances, demands, and challenges facing the hospital and in the particular assigned area (HEMOC) of responsibility.
Job Specific Duties
- Reviews and maintains quality measures for FACT, ACOS, and COG as needed.
- Maintains master plan as required by accreditation bodies, prepares agenda for meetings, & monitors meeting attendance to ensure compliance with all Hematology/Oncology/BMT accreditation standards.
- Coordinates activities related to quality management plan in clinical, apheresis, and processing facilities of Bone Marrow Transplant (BMT).
- Communicates with contracted vendors to monitor compliance of quality measures related to BMT.
- Performs or delegates audits, collects data in clinical, collection and processing facilities, and presents it to the BMT program director.
- Assists the apheresis coordinator in developing policies and developing a system for audits and validations as required by FACT accreditation agency.
- Analyzes quality data collected in Hematology/Oncology and BMT related to readiness and as primary resource, reviews, monitors, and analyzes data.
- Promotes a standard and effective approach to ensure Hematology/Oncology and BMT Unit is continually ready for an accreditation survey.
- Assists the Medical Directors, BMT Coordinator, Cancer Registry, and COG department with accreditation preparation survey. Assumes role of liaison in the absence of Accreditation Administrator.
- Serves as a liaison with NCHS departments, bone marrow, and stem cell processing facility in areas of reporting, quality, and accreditation results/feedback.
- Participates in multi-disciplinary discussion to provide problem solving and expertise.
- Attends ancillary departmental meetings (Tumor Board, BMT, Blue Team, etc.) as required.
Updates standard operating procedures/policies yearly or as required by the accreditation bodies of Hematology/Oncology/ BMT accreditation standards (COC, FACT, COG and ACOS).