MGR - QUALITY & ACCREDITATION

About the position

The George Washington University Hospital (GW Hospital) continues to be a leader in providing the highest level of quality and compassionate healthcare for the D.C. Region. U.S. News & World Report has just released the 2023-2024 ratings and rankings, in which GW Hospital is recognized as a Best Regional Hospital. GW ranks 5th in the region, which includes hospitals in D.C. and parts of Maryland, Virginia and West Virginia. GW Hospital achieved 'High Performing' status in two specialty areas, Neurology and Neuroscience. In addition, GW Hospital receiving 'High Performing' designations for the following 10 procedures: COPD, Diabetes, Heart Attack, Heart Failure, Kidney Failure, Leukemia, Lymphoma and Myeloma, Lung Cancer Surgery, Pneumonia, Prostrate Cancer Surgery and Stroke. Measured by factors such as patient outcomes, 'High Performing' is a designation U.S. News & World Report bestows to recognize performance in these specialties that is significantly better than the national average. GW Hospital received the American College of Cardiology's National Cardiovascular Data Registry (NCDR) Chest Pain - Myocardial Infarction (MI) Registry Platinum Performance Achievement Award for 2023. GW Hospital is the only hospital in Washington, D.C., to be recognized for this service line. 'At GW Hospital, we are proud to offer a range of advanced services and treatments. Our multidisciplinary care teams are dedicated to outstanding clinical services, research, and education to improve care, quality, and outcomes for our patients,' says Ulises Torres, MD, Chief Quality Officer at GW Hospital. 'These recognitions by U.S. News & World Report, which place us within the top hospitals in the region, highlight the expertise, commitment and diligence delivered to each patient in our care.' Children's National Hospital, GW Hospital's NICU partner, was recently ranked the number two hospital in the country for neonatology by U.S. News & World Report. In addition to these recent U.S. News & World Report recognitions, GW Hospital also provides high-quality care in the region through its designation as a Level I Trauma Center and designation as a Comprehensive Stroke Center. The mission of GWU Hospital is to provide the highest quality of healthcare, advanced medical technology, and world class service to its patients in an academic medical center dedicated to education and research.

Responsibilities

• Oversee the implementation of the accreditation plan to ensure a state of continuous survey readiness and compliance with district and federal regulatory requirements.
• Have knowledge or ability to ascertain hospital requirements for accreditations at an academic teaching hospital.
• Ensure an ongoing mechanism for proactive monitoring and auditing is developed, continually updated, and executed on a regular schedule.
• Make the results of any monitoring or auditing available to appropriate leadership.

Requirements

• Experience with management of Regulatory and Accreditation preparedness preferred.
• Master's Degree preferred.
• 3 years experience in an acute care setting.
• Effective written, verbal and interpersonal communication skills.
• Ability to make quality, independent decisions.
• Ability to maintain confidentiality.
• Ability to adapt to multiple and changing priorities.
• Strong analytical and problem solving skills.
• Self-directed.
• Knowledge of licensure regulations, Joint Commission on Accreditation of Healthcare Organization and state/federal standards.
• Knowledge of Performance Improvement methodology and Outcomes Management.
• Statistical analysis skills.
• Demonstrated problem solving, data assembly and action planning ability leading to the development of actions plans that will prove helpful in achieving measurable objectives.
• Ability to organize, formulate, educate and facilitate problem solving teams.
• Demonstrative ability to work without supervision towards a desired outcome.
• Expertise in Microsoft Office and Database management.