Sr Accreditation Specialist

At Houston Methodist, the Senior Accreditation Specialist is responsible for leading the collaboration with medical staff and leadership to provide a global and unified perspective and understanding of accreditation, regulatory and disease-specific certification requirements and activities. The position serves the hospital as an expert resource, mentor, and educator for regulatory, accreditation and certification programs; and works across the hospital to assess, measure, and report ongoing compliance with standards, promote evidence-based best practices, and standardize common survey processes.

Additional responsibilities include functioning as a consultant/surveyor, conducting internal surveys, and providing guidance and direction with on-site or written response and resolution to a regulatory or accreditation survey or complaint investigation.

Exempt

• Bachelor’s degree in nursing or other field relevant to the healthcare industry
• Master’s degree in healthcare or business related field preferred

• Five years of experience in a hospital setting, preferably in patient care or quality
• Three years of experience in one or more of the following: healthcare quality, accreditation or regulatory activities in a healthcare setting; performance improvement; patient safety; infection prevention and control; and/or health information management
• Two years of experience performing accreditation or regulatory activities in a hospital setting

• RN state license or Healthcare Accreditation Certification Program (HACP)

• CPHQ
  - Certified Professional in Healthcare Quality (NAHQ)
  or
• CQA
  - Certified Quality Auditor (ASQ)
  or
• CSHA
  - Certification Specialist in Healthcare Accreditation (HACP)

• Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through on-going skills, competency assessments, and performance evaluations
• Sufficient proficiency in speaking, reading, and writing the English language necessary to perform the essential functions of this job, especially with regard to activities impacting patient or employee safety or security
• Ability to effectively communicate with patients, physicians, family members and co-workers in a manner consistent with a customer service focus and application of positive language principles
• Demonstrated knowledge of regulatory and accreditation requirements (such as Centers for Medicare/Medicaid Services/CMS, The Joint Commission, DNVGL NIAHO/ISO 9001 and/or State requirements)
• Demonstrated expertise in quality/performance improvement tools and techniques; process mapping and flow chart diagrams
• Computer proficiency with intermediate level skills for document, spreadsheet and graphic software (Microsoft Office Word, Excel and PowerPoint)
• Ability to collect qualitative and quantitative data and information; analyze and solve problems
• Strong interpersonal skills and demonstrated ability to work with multidisciplinary groups and teams
• Strong writing and presentation skills; ability to articulate information in a manner that is easily understood
• Ability to demonstrate flexibility in work and assignments; adapt to change
• Self-directed and able to work with minimal supervision; initiative to identify and utilize available internal and external resources
• Proven time management skills and ability to meet deadlines and work under pressure; strong organizational skills with ability to work with multiple projects and tasks
• Ability to discreetly handle sensitive issues in a professional and confidential manner

• Collaborates and effectively communicates with a wide variety of disciplines within the hospital to evaluate, improve, and sustain regulatory and accreditation readiness. Fosters cooperation among departments and disciplines to achieve and sustain ongoing accreditation and regulatory compliance.
• In partnership with hospital leadership, establishes a process to conduct a proactive review of regulatory, accreditation and certification to assess vulnerabilities to compliance with standards.
• Leads process in collaboration with hospital leadership to assign teams to develop corrective action in response to survey findings and facilitate development and implementation of the corrective action processes. Provides guidance and direction to hospital with on-site or written response and resolution to a regulatory or accreditation survey or complaint…