Penn State Health - Milton S. Hershey Medical Center
Location: US:PA: Hershey Work Type: Full Time FTE: 1.00 Shift: Day Hours: 8-Hour Shifts
SUMMARY OF POSITION:
This position is directly responsible for the strategic direction, development, and implementation of the Regulatory & Accreditation and Infection Prevention programs. Responsible for developing, coordinating, integrating, implementing, and maintaining the overall regulatory & accreditation, and infection prevention programs for Penn State Health Milton S. Hershey Medical Center hospital licensure (hospital & ambulatory practice sites of the academic practice division). The director has two primary goals (1) build and maintain a highly reliable continuous survey readiness process to ensure that the organization remains compliant with all Federal, State, and local regulatory requirements, and adheres to identified accreditation and certification program standards and (2) provide leadership and direction for all projects targeting the reduction of healthcare-acquired and occupational infections with the goal of improving clinical outcomes, providing a safe workplace environment, reducing cost, and maintaining compliance with all regulatory requirements. Primary responsibility to direct and oversee any on-site JC or PA DOH accreditation, verification, or complaint survey process. Collect and report hospital-acquired infection data as required by law and other regulations. Meet all internal and external reporting requirement time frames.
Baccalaureate degree in Nursing.
Master's degree related to healthcare or MBA required.
Seven (7) years of experience directly related to Regulatory/Accreditation and Infection Prevention required.
Previous experience in leading Regulatory/Accreditation and Infection Prevention programs in a large health system or complex academic medical center required.
Five (5) years of broad based clinical and management leadership experience required.
Certified Professional in Healthcare Quality (CPHQ), Healthcare Accreditation Certified Professional (HACP) or Joint Commission Professional (CJCP) certificate preferred.
Previous experience in leading Regulatory/Accreditation programs in a large health system or complex academic medical center preferred.
Previous experience managing a complex portfolio of program accreditations and certifications preferred.
Current certification in Infection Prevention preferred.
Previous experience in hospital infection control and epidemiology.
Continuous Improvement certification (Lean, Six Sigma).
This job description is a general outline of duties performed and is not to be misconstrued as encompassing all duties performed within the position. All individuals (including current employees) selected for a position will undergo a background check appropriate for the position's responsibilities.
Penn State Health is fundamentally committed to the diversity of our faculty and staff. We believe diversity is unapologetically expressing itself through every person's perspectives and lived experiences. We are an equal opportunity and affirmative action employer. All qualified applicants will receive consideration for employment without regard to age, color, disability, gender identity or expression, martial status, national or ethnic origin, political affiliation, race, religion, sex (including pregnancy), sexual orientation, veteran status, and family medical or genetic information. If you are unable to use our online application process due to an impairment or disability, please call 717-531-8440 between the hours of 7:30 AM and 4:30 PM, Eastern Standard Time, Monday through Friday, email firstname.lastname@example.org or download our Accommodation Instructions for Job Applicants PDF for more detailed steps for assistance.
At Penn State Hershey, our mission is to enhance the quality of life and serve our community through improved health, the education of health professionals, and the discovery of knowledge. For us, service excellence is not only for our patients but also our employees. It means valuing each and every employee.