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UnityPoint Health Accreditation & Performance Improvement Specialist in Fort Dodge, Iowa

UnityPoint Health- Fort Dodge

Accreditation & Performance Improvement Specialist

FTE 1.0 (Full-time, 40 hours per week)

Shift: Primarily Monday-Friday 8a-4:30p with opportunity for flexible scheduling as needed

Key Accountability

· Serves as an internal expert and consultant for accreditation/ CMS conditions of participation and performance improvement (PI) initiatives

· Serves as liaison to Medical Staff for Accreditation/PI policy/functions as needed

· Provides Accreditation/PI support to hospital and medical staff

· Works directly with healthcare team members and physicians to devise, implement, monitor and analyze PI initiatives

· Designs and implements PI initiatives at UnityPoint Health – Fort Dodge

· Develops PI curriculum, conducts training and implements education and methodologies

· Recognizes consistency and synergy between PI and strategic and business plans

· Conducts Reviews of operational performance systems and assists the improvement teams to clarify specific benchmarks

· Assists with value stream mapping with focus on both local process and organizational needs

· Prepares reports adequately and timely for assigned committees and documents activity appropriately to meet regulatory standards with correct storage and handling of confidential data

· Provides clinical expertise/guidance in collection, interpretation and reporting of data

· Able to work with software programs for statistical process management (or willing to learn)

· Able to work with analytic tools to evaluate performance and opportunities for improving quality and outcomes

· Analyzes data/reports for patterns and trends

· Determines need for databases as appropriate to the project scope

· Ongoing supervision and annual evaluation of databases and monitoring systems

· Interfaces with national benchmarking organizations and UnityPoint Health and Trinity Regional Medical Center (TRMC) workgroups

· Oversight and/or contributions as system administrator for Iowa’s Immunization Registry Information System (IRIS).

· Works directly with healthcare team members and physicians to devise, and implement plans to comply with accreditation standard. Monitors and analyze outcomes related to these plans.

· Provides clinical expertise/guidance in data collection and interpretation for adherence to standards

· Assesses compliance to regulatory standards with recommendations for change

· Conducts training in Accreditation, conducts ongoing internal audits and assists at other affiliates upon request

· Coordinates Internal Audits, Audit Summary Reports, and applicable action plans

· Assists to survey other organizations for compliance to accreditation standards /conditions of participation

· Develops and maintains systems required by accrediting organizations

· Identifies and develops best practices including implementation of evidence-based safety and quality initiatives

· Supports clinical risk management activities

· Supports clinical restraint use management activities

· Suggests applications to meet user needs

· Troubleshoots problems with projects, systems, applications and provides user support

· Participates in medical staff peer review activities

· Maintains positive physician and staff relationships

· Completes the design and/or implementation of special projects

· Supports performance improvement methodologies and education

· Prepares electronic presentations and projects

· Follows through on problems and issues until appropriately resolved

· Performs other duties as needed

Basic UPH Performance Criteria

· Demonstrates the UnityPoint Health Values and Standards of Behaviors as well as adheres to policies and procedures and safety guidelines.

· Demonstrates ability to meet business needs of department with regular, reliable attendance.

· Employee maintains current licenses and/or certifications required for the position.

· Practices and reflects knowledge of HIPAA, TJC, DNV, OSHA and other federal/state regulatory agencies guiding healthcare.

· Completes all annual education and competency requirements within the calendar year.

· Is knowledgeable of hospital and department compliance requirements for federally

funded healthcare programs (e.g. Medicare and Medicaid) regarding fraud, waste and abuse. Brings any questions or concerns regarding compliance to the immediate attention of hospital administrative staff. Takes appropriate action on concerns reported by department staff related to compliance.


Bachelor’s degree in nursing or health care related field, or working toward


3 years successful employment in related field


Valid driver’s license when driving any vehicle for work-related reasons. As required by profession


Effective written/verb Effective written/verbal communication skills. Basic knowledge of computer concepts, information systems. Ability to meet time frames for work completion. Effective skills at team work and team facilitation. Commitment to maintaining a high level of competence in accreditation and performance improvement concepts.


Use of usual and customary equipment used to perform essential functions of the position.

Requisition ID: 2021-101856

Street: 802 Kenyon Rd

Name: 7020 UnityPoint Health Trinity Regional Medical Ctr

Name: Quality Improvement

FLSA Status: Non-Exempt

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