System Accreditation Specialist

• Collaborates and effectively communicates with a wide variety of disciplines, including all levels of staff, leadership and medical staff across the system to facilitate, evaluate, improve, and sustain regulatory and accreditation compliance.

• Reviews regulatory and accreditation resources on an ongoing basis to identify updates (CMS Conditions of Participation, State Hospital Licensing Rules and other relevant accreditation and certification program standards); communicates updates to hospital entities and relevant corporate departments.

• Facilitates communication and assessment of needs for processes and practices to comply with new or revised requirements.

• Provides consultative guidance, interpretation and direction related to regulatory and accreditation requirements for policy-procedure, electronic medical record, system and entity committees or councils, and pre-survey, survey and post-survey activities.

• Develops, conducts and evaluates education and training programs or other resources related to regulatory and accreditation requirements.

• Prepares for and conducts department and system-wide meetings to include agenda, applicable reports and materials, minutes (or summary of previous meeting discussion and actions), and related data for applicable performance measures.

• Develops, implements and evaluates strategies to meet and sustain regulatory and accreditation compliance; promotes continual improvement in compliance with standards, including ISO 9001 Quality Management System.

• Conducts internal surveys across the HM system using ISO 9001 process audit tools and techniques to evaluate the effectiveness of actions taken for previous survey findings, perform a risk assessment of survey findings from across the system, and/or identify potential risks related to new or revised requirements; provides report of survey findings, relevant standard references and recommendations for improvement.

• Communicates survey findings to relevant corporate department and entity stakeholders; maintains a library of current and past survey reports.

• Collects, aggregates, and analyzes survey data and trends across the system; identifies opportunities for improvement; reports aggregate results and analysis through appropriate entity and system venues.

• Coordinates content development and implementation of system-wide documents or materials with a regulatory or accreditation impact.

• Utilizes efficient and cost-effective work practices with department resources and supplies; provides recommendations to reduce expenses; enters reimbursable business expenses in a timely manner.

• Remains current with regulatory and accreditation program requirements and best practices through available resources such as conferences, internet-based learning, review and research of specific program materials, and/or professional journals.

• Identifies and participates in opportunities to standardize and align practices across the system (such as policy and procedure, entity processes, patient and other organizational materials); shares innovative and best practices with entity Quality and Patient safety leaders, system councils or committees, and relevant corporate departments.

• Facilitates resolution of system-wide survey nonconformities between entities and corporate departments.

• Bachelor's degree in nursing or other healthcare related field; may consider HM employee with Registered Nurse license and four additional years of directly related experience (in addition to the minimum experience requirements listed below) in lieu of bachelor's degree

• 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 hospital setting; patient safety; infection prevention and control; and/or health information management

• N/A

• CPHQ - Certified Professional in Healthcare Quality (NAHQ) -- Related quality, accreditation or health care certifications OR
• CQA - Certified Quality Auditor (ASQ) -- Related quality, accreditation or health care certifications OR
• HACP - Healthcare Accreditation Certification Program (CIHQ) -- Related quality, accreditation or health care certifications OR
• CSHA - Certification Specialist in Healthcare Accreditation -- Related quality, accreditation or health care certifications OR
• RHIA - Registered Health Information Administrator (AHIMA) -- Related quality, accreditation or health care certifications

• 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

• Knowledge of health care regulatory and accreditation requirements (such as Centers for Medicare/Medicaid Services/CMS, CMS approved hospital accreditation organizations and State requirements)

• Proficient with intermediate computer level skills for document, spreadsheet and graphic software (such as Microsoft Office Word, Excel and PowerPoint)

• Expertise in quality or performance improvement tools and techniques, process mapping and flow chart diagrams

• Ability to collect qualitative and quantitative data and information; analyze and apply data to problem-solving and improvement activities

• Self-directed and able to work with minimal supervision; initiative to identify and utilize available internal and external resources; flexibility in work and assignments; adapts to change

• Proven time management skills and ability to meet deadlines and work under pressure; strong organizational skills and ability to prioritize multiple projects and tasks

• Strong interpersonal skills and ability to work with multidisciplinary groups and teams

• Strong and effective verbal and written communication skills with audiences at various levels in the organization; ability to articulate information in a manner that is easily understood

• Ability to discreetly handle sensitive issues in a professional and confidential manner

• Uniform No
• Scrubs No
• Business professional Yes
• Other (department approved) No

• On Call* No

• May require travel within the Houston Metropolitan area Yes
• May require travel outside Houston Metropolitan area Yes

Houston Methodist