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Accreditation Specialist-RN/ Quality Care Mgmt Dept. (F/T)

Location: Houston Methodist Willowbrook Hospital
18220 State Highway 249
Houston, TX 77070
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Talent Area:
Job Shift:
1st - Day
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Posted Date:
April 25, 2024

At Houston Methodist, the Accreditation Specialist position is responsible for collaborating 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 a resource, mentor, and educator for regulatory, accreditation and certification programs; works across the hospital to assess, measure, and report ongoing compliance with standards, promote evidence-based best practices, and standardize common survey processes.


  • 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.
  • Collaborates 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.

  • Supports and participates in hospital pre-survey, on-site survey, and post-survey activities for accreditation, regulatory and disease-specific certification programs. Coordinates and participates in internal surveys using ISO 9001 process audit tools and techniques to assess and evaluate ongoing survey readiness.
  • Communicates survey findings to hospital leadership. Provides support and guidance for survey follow-up including review and feedback related to corrective action plans.
  • Provides education and training related to regulatory, accreditation, and disease-specific certification requirements.
  • Functions as a liaison with accreditation and regulatory agencies, such as serving as first point of contact and updating hospital profile information.

  • Facilitates resolution of survey nonconformities through monitoring the progress of corrective action plans on an ongoing basis. Conducts internal surveys with hospital survey teams to review and evaluate the implementation, effectiveness and sustainability of survey corrective action plans; provides reports from the surveys to hospital leadership and Accreditation and Regulatory department on the status of survey findings' resolution and progress.
  • Participates in the development, review and evaluation of an ongoing regulatory and accreditation program that promotes continual improvement of compliance with standard requirements, including ISO 9001 Quality Management.
  • Conducts ongoing monitoring, measurement and analysis of survey data and trends; communicates aggregate results and analysis to appropriate hospital department staff and leadership.

  • 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.

  • 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.
  • 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.


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

  • Three years of experience in a hospital setting, preferably in patient care or quality
  • One year 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
  • 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

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


  • 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)
  • Working knowledge of quality/performance improvement concepts, 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



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

*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 specifications may vary by department**

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

Company Profile:

Houston Methodist Willowbrook Hospital is a Magnet-recognized, not-for-profit, faith-based hospital that serves the growing Northwest Houston community. With 358 licensed beds, Houston Methodist Willowbrook is committed to providing quality, cost-effective health care in a compassionate environment for a full range of services, including emergency care, cardiology, orthopedics and sports medicine, comprehensive women’s services, neurology and neurosurgery, oncology, and primary and general medicine.

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.

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