Houston Methodist

Nonprofit academic medical center with hospitals

Senior Accreditation Specialist

Regulatory Compliance & EthicsConfirmed live in the last 24 hours

Full-timeHouston, TX, USANo salary listed

About the Job

Requirements

A bachelor's degree in nursing or another field relevant to the healthcare industry is required.
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 areas in a healthcare setting: healthcare quality, accreditation or regulatory activities, performance improvement, patient safety, infection prevention and control, or health information management.
Two years of experience performing accreditation or regulatory activities in a hospital setting.
A state registered nurse license or Healthcare Accreditation Certification Program certification is required.
Proficiency in speaking, reading, and writing English sufficient to perform the essential job functions, especially those affecting patient or employee safety or security.
Knowledge of regulatory and accreditation requirements, such as Centers for Medicare and Medicaid Services, The Joint Commission, DNVGL NIAHO/ISO 9001, or state requirements.
Expertise in quality and performance improvement tools and techniques, process mapping, and flowchart diagrams.
Intermediate computer proficiency with document, spreadsheet, and graphic software, including Microsoft Word, Excel, and PowerPoint.
Ability to collect qualitative and quantitative data and information, analyze information, and solve problems.
Strong writing and presentation skills, including the ability to explain information clearly.
Ability to work flexibly across assignments and adapt to change.
Ability to work with minimal supervision and identify and use available internal and external resources.
Time-management and organizational skills, including the ability to meet deadlines and manage multiple projects and tasks under pressure.
Ability to handle sensitive issues professionally and confidentially.

Responsibilities

Collaborate and communicate with disciplines across the hospital to evaluate, improve, and sustain regulatory and accreditation readiness, and foster cooperation to achieve ongoing compliance.
Partner with hospital leadership to establish a proactive review process for regulatory, accreditation, and certification requirements and assess compliance vulnerabilities.
Lead the process of assigning teams with hospital leadership to develop corrective actions in response to survey findings, and facilitate their development and implementation.
Provide guidance and direction for on-site or written responses and resolution of regulatory or accreditation surveys or complaint investigations as needed.
Support and participate in pre-survey, on-site survey, and post-survey activities for accreditation, regulatory, and disease-specific certification programs.
Serve as a consultant and surveyor, and conduct internal surveys using ISO 9001 process audit tools and techniques to assess ongoing survey readiness.
Communicate survey findings to Quality and Patient Safety leadership and other hospital quality and patient safety departments.
Communicate updates to regulatory, accreditation, and certification standards; support, guide, assess, and evaluate hospital implementation of compliant processes and practices; and provide related education and training.
Serve as a primary contact for accreditation and regulatory agencies and independently manage hospital profile information.
Facilitate implementation and resolution of survey corrective actions, and review and evaluate their implementation, effectiveness, and sustainability.
Track, trend, and analyze survey nonconformities and identify improvement opportunities and best practices.
Develop and evaluate an ongoing regulatory and accreditation readiness program that promotes continual improvement, including ISO 9001 Quality Management and gap analyses.
Facilitate resolution of survey nonconformities through collaborative and proactive action plans.
Participate in annual budget preparation, expense projections, and justifications.
Use department resources and supplies efficiently and cost-effectively, and recommend expense reductions.
Keep current with regulatory, accreditation, and certification changes through conferences, online learning, program materials, research, and professional journals.
Communicate innovative approaches and best practices to hospital quality and patient safety departments and leadership, and identify opportunities to align policies and procedures with regulatory and accreditation requirements.
Acquire, use, and teach performance improvement concepts and techniques, including ISO 9001 and Lean.

Desired Qualifications

A master's degree in a healthcare- or business-related field is preferred.
Hospital experience in patient care or quality is preferred.
Certified Professional in Healthcare Quality certification from NAHQ, Certified Quality Auditor certification from ASQ, or Certification Specialist in Healthcare Accreditation certification through HACP is preferred.

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.

FLSA STATUS
Exempt

QUALIFICATIONS

EDUCATION

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

EXPERIENCE

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

LICENSES AND CERTIFICATIONS
Required

RN state license or Healthcare Accreditation Certification Program (HACP)

Preferred

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

SKILLS AND ABILITIES

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

ESSENTIAL FUNCTIONS

PEOPLE ESSENTIAL FUNCTIONS

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 investigation as needed.

SERVICE ESSENTIAL FUNCTIONS

Supports and participates in hospital pre-survey, on-site survey, and post-survey activities for accreditation, regulatory and disease-specific certification programs. Functions as a consultant/surveyor and conducts internal surveys using ISO 9001 process audit tools and techniques to assess and evaluate ongoing survey readiness.
Communicates survey findings to Quality & Patient Safety leadership and other hospital quality/patient safety (accreditation/regulatory) departments.
Communicates updates to regulatory/accreditation/certification standards. Provides support, guidance, assessment and evaluation of hospital implementation of processes and practices to comply with new or revised requirements. Provides education and training related to regulatory and accreditation requirements.
Serves as a primary source of contact with accreditation and regulatory agencies; manages hospital profile information independently.

QUALITY/SAFETY ESSENTIAL FUNCTIONS

Facilitates implementation and resolution of survey corrective action processes; provides ongoing review and evaluation of the implementation, effectiveness and sustainability of corrective action plan processes. Tracks, trends and analyzes survey nonconformities; identifies opportunities for improvement and best practices.
Develops and evaluates processes for an ongoing regulatory and accreditation readiness program that promotes continual improvement in compliance with standards, including ISO 9001 Quality Management and performing gap analyses.
Facilitates resolution of survey nonconformities through development of collaborative and proactive action plans.

FINANCE ESSENTIAL FUNCTIONS

Participates in annual budget preparation, expense projections and justifications.
Utilizes efficient and cost-effective work practices with department resources and supplies; provides recommendations to reduce expenses.

GROWTH/INNOVATION ESSENTIAL FUNCTIONS

Remains current with regulatory, accreditation and certification changes through available resources such as conferences or internet-based learning, reviewing and researching specific program materials, and/or reviewing professional journals.
Communicates innovative and best practices to hospital quality and patient safety departments and leadership. Identifies opportunities to align policy and procedure with regulatory/ accreditation requirements.
Enhances continual improvement activities by acquiring, utilizing and teaching performance improvement concepts and techniques, such as ISO 9001 and LEAN.

SUPPLEMENTAL REQUIREMENTS

WORK ATTIRE

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

ON-CALL*

*Note that employees may be required to be on-call during emergencies (ie. Disaster, Severe Weather Events, etc) regardless of selection below.

On Call* No

TRAVEL**

**Travel specifications may vary by department**

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

Work Shift:

1 - Day (United States of America)



Job Category:

Non-clinical

Houston Methodist Hospital is recognized by U.S. News & World Report as the No. 1 hospital in Texas and one of America’s “Best Hospitals.” As a full-service, acute-care hospital located in the Texas Medical Center and the flagship hospital of Houston Methodist, it has evolved into one of the nation’s largest nonprofit teaching hospitals and a leader in innovative medical research with a comprehensive residency program. Two of Houston Methodist’s primary academic affiliates are among the nation’s leading health care organizations: Weill Cornell Medicine and New York-Presbyterian Hospital. Houston Methodist also has affiliations with Texas A&M University and the University of Houston. Houston Methodist Hospital offers unparalleled care for thousands of patients from around the world.


Houston Methodist is an Equal Opportunity Employer.

About the Company

Houston Methodist

Nonprofit academic medical center with hospitals

Houston Methodist is a nonprofit academic medical center and hospital system in the Houston area. It delivers fee-for-service care through eight hospitals, focusing on cancer, heart and vascular care, transplantation, neurosciences, orthopedics, and digestive disorders, and treats thousands of international patients. The system combines patient care with research, education, and philanthropy through the Houston Methodist Hospital Foundation, with its flagship at the Texas Medical Center and partnerships with Weill Cornell Medicine, Texas A&M, and Rice University that support programs like EnMed and a broad clinical trials network via the Houston Methodist Research Institute. Its goal is to improve patient outcomes by providing high-quality medical care while expanding research, education, and collaborative clinical programs.

Company size: 10,001+
Company stage: Not listed
Total funding: Not listed
Headquarters: Houston, TX
Founded: 2008

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