This is the clinical expert. At a professional level, facilitates quality improvement and assists departments with quality management efforts. Establishes, monitors and evaluates standards of performance to enhance patient care. Collects, aggregates, and maintains records of data attained. May serve as the educator for quality improvement.
Responsible for leading and/or assisting with system-wide activities to evaluate and improve adherence to The Joint Commission (TJC) accreditation standards and CMS Conditions of Participation (CoPs). This includes ongoing readiness for accreditation surveys as well as regulatory complaint investigations. The mitigation of regulatory compliance risk will at all times focus on assuring the delivery of safe patient care.
* Serve as a resource for interpretation of regulatory, accreditation and disease-specific care certification standards (as applicable).
* Interpretation of relevance of standards in relation to hospital/department policies and practices.
* Performs concurrent and closed medical record review audits to assist in determining compliance with accreditation and regulatory requirements.
.* Conducts patient and system tracers in patient care areas through observation of practice.
* Collects, analyzes and reports data in support of continuous readiness activities.
* Disseminates the results of audits and surveillance results as needed.
* Assist in assuring accuracy and timeliness in submission of corrective action plans to internal stakeholders and external agencies.
Our Mission: WHY WE EXIST. To extend the healing ministry of Jesus Christ. Our Core Values: WHAT WE BELIEVE IN.DIGNITY Respect for the worth of every person, recognition and commitment to the value of diverse individuals and perspectives, and special concern for the poor and underserved. INTEGRITY Honesty, justice, and consistency in all relationships. EXCELLENCE High standards of service and per...formance. COMPASSION Service in a spirit of empathy, love, and concern. STEWARDSHIP Wise and just use of talents and resources in a collaborative manner.Our Vision: WHAT WE ARE STRIVING TO DO. CHRISTUS HEALTH, a Catholic health ministry, will be a leader, a partner and an advocate in the creation of innovative health and wellness solutions that improve the lives of individuals and communities so that all may experience God's healing presence and love. Our Name and Symbol:WHO WE ARE. CHRISTUS is Latin for "Christ," and proclaims publicly the core of our mission. OUR NAME choice also recognizes the heritage of our two congregational sponsors, the Sisters of Charity of the Incarnate Word in Houston and San Antonio. Jesus Christ is the Incarnate Word, the Word of God made flesh. It is, therefore, only fitting that it is in another form of His name that our health ministries are called together. OUR SYMBOL Reflects the healing ministry of Jesus Christ - a combination of a medical cross and a religious cross. The flowing banner on the cross is a common symbol of the risen Christ, while the royal purple signifies Christ. The flowing banner also conveys a sense of motion as we move forward into a new era of service to our communities.