Facility Overview: Trauma Level: ll or lll Nurse-Patient Ratio: NA Type of Facility: Hospital Bed-Size: 50-149 Job Responsibilities: Monitors and collaborates to ensure technical and quality compliance with governmental/regulatory rules and regulations. Coordinates management action plans for accreditation – ongoing / continual readiness for accreditation surveys (a) The Joint Commission, (b) Healthcare Facilities Accreditation Program, (c) CMS Conditions of Participation, and others as needed to obtain or maintain hospital accreditation or certifications. Essential to this responsibility is the collection, abstraction, analysis and reporting of clinical data. Develops systems and procedures to carry out QM/PI functions in alignment with accreditation/regulatory agencies and professional quality organizations, such as the Agency for Healthcare Research and Quality (AHRQ).