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.

PATIENT AGE GROUP(S) AND POPULATION(S) SERVED
Refer to departmental "Scope of Service" and "Provision of Care" plans, as applicable, for description of primary age groups and populations served by this job for the respective HM entity.

HOUSTON METHODIST EXPERIENCE EXPECTATIONS

• Provide personalized care and service by consistently demonstrating our I CARE values:
  • INTEGRITY: We are honest and ethical in all we say and do.
  • COMPASSION: We embrace the whole person including emotional, ethical, physical, and spiritual needs.
  • ACCOUNTABILITY: We hold ourselves accountable for all our actions.
  • RESPECT: We treat every individual as a person of worth, dignity, and value.
  • EXCELLENCE: We strive to be the best at what we do and a model for others to emulate.

• Practices the Caring and Serving Model

• Delivers personalized service using HM Service Standards

• Provides for exceptional patient/customer experiences by following our Standards of Practice of always using Positive Language (AIDET, Managing Up, Key Words)

• Intentionally collaborates with other healthcare professionals involved in patients/customers or employees' experiential journeys to ensure strong communication, ease of access to information, and a seamless experience.

• Involves patients (customers) in shift/handoff reports by enabling their participation in their plan of care as applicable to the given job

• Displays cultural humility, diversity, equity and inclusion principles

• Actively supports the organization's vision, fulfills the mission and abides by the I CARE values

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.

This job description is not intended to be all-inclusive; the employee will also perform other reasonably related business/job duties as assigned. Houston Methodist reserves the right to revise job duties and responsibilities as the need arises.

EDUCATION

• Bachelor's degree in nursing or other field relevant to the healthcare industry

• Master's degree in healthcare or business related field preferred

WORK 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 - Registered Nurse - Texas State Licensure and/or Compact State Licensure within 60 days OR
• RN-Temp - Registered Nurse - Temporary State Licensure within 60 days AND
• For other clinicians: Current license/certification as required by the credentialing body for the respective clinical discipline

LICENSES AND CERTIFICATIONS - PREFERRED

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

KNOWLEDGE, 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

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

Houston Methodist West Hospital is committed to leading medicine in West Houston, Katy and surrounding communities by delivering the Houston Methodist standard of exceptional safety, quality, personalized service and innovation. The growing campus offers more than 200 beds, 19 operating rooms and over 1,500 employees, with access to the most innovative medical and surgical care available, including robotic and minimally invasive surgery, full-spectrum heart care, state-of-the-art imaging, cancer care, labor and delivery with a level II neonatal ICU, neurology and neurosurgery, orthopedics and sports medicine, outpatient rehabilitation and 24/7 emergency services.