Jane Wilson, Program Director Accreditation and Certification, Office of Quality, serves as EHC's primary liaison with our regulatory agencies (The Joint Commission (TJC), CMS, DCH (state), and others.) In her role, she has established a systematic approach to "readiness" by building a team of Accreditation Managers across all OUs. Jane engages the managers in developing standard work and backing each other up. For example, when a survey occurs, the entire team helps that OU with the survey. In addition, she led the effort to have a chapter leader model at each OU, which assigns responsibility among the OU leaders for ongoing assessment of compliance with CMS standards of care. 

In addition to her work with accreditation, Jane leads similar efforts to standardize and systemize our certifications (stroke and bariatric) across Emory Healthcare. A third area of focus is our Policy Management team (also led by Jane.) Tremendous progress has occurred by implementing an electronic document control system (Policy Manager) and coordinating efforts across OUs to streamline policies from over 6000 to approx. 4000. (Motivates staff with a shared vision and enthusiasm to achieve better outcomes for staff and patients.) Jane represents Emory Healthcare on several boards and committees at TJC and stays at the forefront of any changes to standards. This allows her to keep our OU-specific leaders up to date. Her efforts to provide professional development for the team have led to several of our managers achieving professional certification in accreditation. (Demonstrates extraordinary nursing care in alignment with Emory Healthcare Values (Caring, Accountability, Integrity & Excellence) within the organization, community, and the profession) Jane holds retreats for each team (Accreditation team, Stroke team, and Policy Management Office) across the system for standardization and professional development. 

Due to EHC's current financial situation, she has provided meals and refreshments during retreats at her own personal expense. These efforts have increased teamwork, provided professional development, and fostered a sense of belonging for these team members. (Models empathy and demonstrates a caring attitude in all situations.) I have received positive feedback from many leaders across EHC about Jane's value to their work. She has changed the attitude toward surveys and certification from a "got 'cha" mentality to a coordinated effort between Quality, Nursing, physicians, and Operations to ensure that best practices are implemented and maintained at all times. (Establishes a special connection with patients, families, co-workers, and other colleagues and promotes an inclusive environment for all.) In summary, Jane has moved EHC from a "siloed" approach for accreditation, certifications, and policies to a system approach, which is more efficient and improves patient safety and team member satisfaction. In addition, Jane has changed our culture from "pass the test" always to ensure that we follow best practices to keep our patients and each other safe.