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Lodi Health Physician Jobs
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RN Job In Lodi, CA

Accreditation and Patient Safety Director

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Company: Lodi Memorial Hospital Profession/Specialty: RN Location: Lodi, California 95240
Job Description

DEPARTMENT:          Quality Management Services

TITLE:                        Accreditation and Patient Safety Director

REPORTS TO:             Executive Director of Quality 

SUMMARY:                Under the direction of the Executive Director, this position is accountable and responsible for designing and implementing systems to ensure a state of continual regulatory, licensure and accreditation compliance as well as oversight of patient safety programs.  This individual will provide specific support and coordination for the hospital during agency visits and surveys.  Supports the accreditation preparation process for the organization by managing logistics for the patient tracer program, conducting mock surveys and maintaining organization’s communication regarding changes and updates for regulatory compliance.  Coordinates variety of projects within the organization to support the strategic goals of the hospital.  This individual must demonstrate the ability to manage multiple tasks and projects in a productive manner, demonstrate teamwork, and collaboration with management and staff within the organization.



1.                  California Registered Nurse license

2.                  Bachelor’s degree in Nursing

3.                  3 years of current work experience in quality or accreditation

4.                  Previous experience in hospital setting, including experience in performance improvement, data collection and reporting

5.      Experience in presenting, educating and public speaking

6.      Sufficient knowledge of Joint Commission, Title XXII, CDPH and CMS standards and requirements

7.      Proficient with hospital based computer software, with skills in Microsoft Word, Web-based data       systems, and Excel


1.                  Masters of Science Degree in Nursing, Healthcare Administration, or Business Administration

2.      Healthcare Accreditation Certificated Professional (HACP)

3.         Certified Professional in Healthcare Quality (CPHQ)


1.                  Reviews, interprets and assists hospital departments, leadership and Medical Staff in the implementation of applicable federal, state and Joint Commission standards and regulations.

2.                  Maintains and controls all regulatory, licensure and accreditation documents.

3.                  Monitors Joint Commission standards compliance on an ongoing basis, maintaining a constant state of readiness for survey.  Consults on potential risks dealing with all regulatory standards, (federal, state and local).


4.                  Acts as a liaison with hospital departments to support mechanisms to drive standard compliance.

5.                  Plans and conducts in-service education and training programs for hospital staff, medical staff and leadership regarding the regulatory process and changes requiring general hospital staff education.

6.                  Identifies and assesses quality and risk information to collaborate and prepare corrective action plans for hospital compliance.  Tracks and trends regulatory compliance issues and identifies resources to correct deviations from regulation.

7.                  Leads or provides support for assigned hospital and department committees and projects.  This includes collaboration with management, medical staff and administration with information regarding current accreditation status and survey process.  Provides input on service or process design to assure regulatory compliance.

8.                  Provides direction and consultation to policy/procedure review/revision to assure regulatory compliance.

9.                  Manages the Verge website for concurrent regulatory and standard assessment, supporting the Focused Standards Assessment (FSA) data bank, assures measurement of all required FSA elements, and coordinates completion of FSA and submission to the Joint Commission.

10.              Leads all on site regulatory, licensure and accreditation surveys including but not limited to:  Joint Commission, State Department of Public Health Services, CMS, OSHA, or FDA.

11.              Coordinates the JC survey process and application, as well as the command center and appropriate hospital representation for surveyor escorts.

12.              Organizes schedules and conducts internal audit process to measure survey readiness (mock surveys, tracer activities and organizational inspections).

13.              Develops and maintains any action plan and response to citations for any regulatory agency.

14.              Provide oversight of the processing of all application requests, initial applications, reapplications, and proctoring to insure all credentialing requirements have been met in accordance with regulatory and accreditation requirements for membership and privileges of medical staff and allied health practitioners.

15.              Representative of the Quality Department for risk-based programs.

16.              Manage and develop the Patient Safety Program in coordination with the Patient Safety Officer of the Medical Staff.

17.              Oversight of the Infection Prevention program and Center of Excellence accreditation programs.

18.              Supervise the employees within the department in a professional, fair manner. 


1.                  Conducts hospital and department business in an ethical and lawful manner, and willing to report any knowledge of real or potential fraud or abuse according to the LMH Compliance Code of Conduct.

2.                  Will not use or disclose individually identifiable health information of patients over and above that which is minimally required to perform your assigned position responsibilities.


1.         The Accreditation & Regulatory Supervisor is responsible for the program throughout the Lodi Memorial Hospital Organization.  This requires travel to different campuses; therefore, a current California driver’s license with acceptable record and insurance coverage per Human Resources policy is required.

2.         Typical office environment with use of office equipment, as well as frequently walking about the facility to different patient care units.

3.         Duties and responsibilities may be added, deleted or changed at any time at the discretions of the Director or designee, formally or informally, either verbally or in writing.


  1. Must be able to walk, stand, stoop, and lift.Must be able to sit for long periods of time.
  2. Must exhibit visual and auditory acuity and good manual dexterity.
  3. Must be able to lift twenty-five (25) pounds safely.
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Lodi Health Physician Jobs
About Lodi Health

Lodi Health is a private, not-for-profit health system that strives to improve the quality of life in the community it serves - both in and beyond its walls. As a non-profit, unaffiliated health system, Lodi Health is able to reinvest in talent, technology and physicians to ensure patients receive quality and very personal care.

Since April of 1952 when the Lodi Memorial Hospital's doors first opened, until today, Lodi Health has evolved to meet the changing community's need. In 1952, there were 14,000 residents in Lodi. Today there are 65,000, and the area served beyond Lodi's boundaries has grown to more than a quarter million people.

Over the last 63 years, a lot has changed at Lodi Memorial Hospital. New buildings and wings have been erected. New technologies, like robotic-assisted surgery, have been introduced. Quality physicians and dedicated nurses have worked round the clock. Lodi Memorial Hospital became Lodi Health to encompass all of its services that provide the quality health care you need with the compassion and personal attention you want from the first day of your life and every day thereafter.

Our vision is to be the first choice for health care by providing the highest level of quality, care access, wellness and affordability through partnerships with patients, staff, physicians and the community we serve.

Now, Lodi Health is pleased to join the Adventist Health family, which allows for even greater service in Lodi and its surrounding communities.

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