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Accreditation Coordinator (RN) Registered Nurse

Job Ref: 26313

Talent Area: RN - Performance Improvement/Quality

Houston Methodist Willowbrook Hospital
Houston, TX 77070

Area/Department: Qual Care Mgmt

Employment Type: Regular

Job Type: Full-Time

Organization: Houston Methodist

Work Shift: DAY

Work Week: M - F

Company Profile

Houston Methodist Willowbrook Hospital opened its doors to Northwest Houston in December 2000. In May 2010, a major expansion on the 52-acre campus doubled the size of the hospital, brining more expertise, more state-of-the-art technology and more specialized care to the community. With 251 licensed beds, 16 operating rooms and over 1,600 employees, Houston Methodist Willowbrook Hospital was specifically designed to provide comprehensive, personalized care for the community.

Job Summary


The  Accreditation Coordinator-RN is responsible for working with Methodist Willowbrook Hospital leadership, hospital staff, physicians and mid-level providers to assess, plan, improve and maintain compliance with regulations set forth by the Center for Medicare/Medicaid Services (CMS) and Det Norske Veritas (DNV) and ISO 9001:2008.  The Coordinator acts as a resource for the medical staff, executive leadership, and hospital staff.  In addition, this position has the accountability for assisting with the quality and patient safety program including but not limited to: chart review, data analysis, report production, and presentation of information at the necessary leadership and medical staff meetings.






  1. Conducts proactive risk assessments on vulnerabilities as defined by the accreditation standards. (EF)
  2. Develop, implement, maintain and improve pre-survey activities that foster collaboration among all disciplines involved in the care of these specific patient populations.(EF)
  3. Provision of education related to NIAHO, ISO, and the CMS Conditions of Participation to hospital staff. (EF)
  4. Assists and facilitates in the coordination, implementation, and monitoring of processes that become system processes. (EF)
  5. Responsible for providing ongoing support and assistance to the hospital, in meeting the DNV supported accreditation. This includes facilitating and or leading teams, committee participation, and participation in Focused Rounding and facilitating Corrective Action Teams.(EF)
  6. Functions as a Lead Auditor. Facilitates collaborative participation from the participating disciplines developing the compliance report and works with departmental leadership to accomplish same. (EF)
  7. Maintains up-to-date knowledge of DNV, ISO 9001, Performance Improvement, and Patient Safety.
  8. Promotes and leads performance improvement activities throughout the hospital including reporting of such activities, as assigned.  Such activities include but not limited to:  data abstraction, data entry, analysis, developing reports, and report presentation at assigned committees/meetings.
  9. Provides reports of performance improvement and patient safety activities to assigned areas of responsibility. 
  10. Collaborates and effectively communicates with a wide variety of disciplines within the system to evaluate, improve, and sustain performance improvement initiatives while serving as a resource for those efforts.
  11. Demonstrate Service PRIDE standards.
  12. Demonstrate ICARE values.
  13. Follows all safety rules on the job.
  14. Performs other duties as assigned.


Bachelor’s degree in Nursing

Master’s degree desired.



A minimum of 5 years experience in a hospital setting preferably in patient care or quality. Related regulatory experience preferred.


Demonstrated application of process/performance improvement principles.



Registered Nurse with current Texas license



  1. Knowledge of Centers for Medicare/Medicaid Services, ISO Clauses, NIAHO Requirements, Joint Commission and DNV.
  2. Knowledge of regulatory and accreditation requirements as they relate to   performance improvement and patient safety.
  3. Strong knowledge of process improvement tools and techniques.
  4. Strong interpersonal skills and demonstrated ability to work with multidisciplinary groups and teams.

5.  Skilled in verbal and written communication.

6.  Ability to analyze and solve problems.

7.  Ability to work independently and interdependently.

8.  Appreciation of cultural diversity and sensitivity towards target populations.

9.  Proven time management skills and able to meet deadlines.

10.  Strong leadership qualities and public speaking ability.



Activity Checklist attached


1.  Normal office conditions

2.  Prolonged sitting, standing, or walking may be required.

3.  Use of personal computer.

4.  Activities may be in hospital units or support departments such as facilities with typical hazards and concerns.

5.  Travel to off-site locations will occur.

Equal Employment Opportunity

Houston Methodist is an Equal Opportunity Employer.

Equal employment opportunity is a sound and just concept to which Houston Methodist is firmly bound. Houston Methodist will not engage in discrimination against or harassment of any person employed or seeking employment with Houston Methodist on the basis of  race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, status as a protected veteran or other characteristics protected by law.

VEVRAA Federal Contractor – priority referral Protected Veterans requested.