Senior Accreditation Specialist
Job Ref # 24590
Location: Houston, TX
Category: Professional
Job Type: Full-Time

Work Shift: DAY

Work Week: M - F

Job Summary

The Sr. Accreditation Specialist is responsible for working with assigned Houston Methodist hospital quality, medical staff and leadership to plan, assess, develop and implement processes to improve and sustain ongoing compliance with regulatory, accreditation and disease specific certification programs  The position serves as a resource, mentor, consultant and educator for regulatory, accreditation and certification programs; coordinates on-site survey activities; and participates in strategies for planning, development, implementation and evaluation of the regulatory, accreditation and certification programs.

Select the applicable age group(s) of primary customers/patients served by this position.

¿ Not applicable
¿ Neonate (Birth to 28 days)
¿ Infants/Toddlers (29 days to 18 months)
¿ Toddler (18 months to 3 years)
¿ Preschooler (3-6 years)
¿ School Age (6-12 years)
¿ Adolescence (12-18 years)
¿ Young Adult (19-40 Years)
¿ Middle Adult (40-65 Years)
¿ Mature Adult (65 years and older)


I. 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. 

II. Focuses on patient/customer safety
III. Delivers personalized service using HM Service Standards
IV. Provides for exceptional patient/customer experiences by following our Standards of Practice of always using Positive Language (AIDET, Managing Up, Key Words)
V. Intentionally rounds with patients/customers to ensure their needs are being met
VI. Involves patients (customers) in shift/handoff reports by enabling their participation in their plan of care as applicable to the given job

Duties and Responsibilities are cross-referenced to Houston Methodist¿s Pillars of Excellence and will be transferred to the Performance Evaluation.

PEOPLE ¿ 10%
1. Collaborates and effectively communicates with a wide variety of disciplines within the hospital to evaluate, improve, and sustain regulatory and accreditation readiness. (EF)
2. Provides guidance and direction to hospital with on-site or written response and resolution to a regulatory or accreditation survey or complaint investigation.  (EF)

1. Supports and participates in hospital pre, on-site post survey activities for accreditation, regulatory and disease-specific certification programs.  (EF)
2. Communicates survey findings to Quality & Patient Safety leadership and other hospital quality/patient safety (accreditation/regulatory) departments.  (EF)
3. Provides support and guidance for survey follow-up including review and feedback related to corrective action plans.  (EF)
4. 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.  (EF)
5. Provides education and training related to regulatory and accreditation requirements.  (EF)
6. Prepares for and conducts department and hospital 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. (EF)

1. 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.  (EF)
2. Functions as a consultant/surveyor and conducts (mock) surveys using ISO 9001 process audit tools and techniques to assess and evaluate ongoing survey readiness.  (EF)
3. Tracks, trends and analyzes survey nonconformities; identifies opportunities for improvement and best practices.  (EF)
4. 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.  (EF)
5. Facilitates resolution of survey nonconformities through development of collaborative and proactive action plans.  (EF)
6. Conducts ongoing monitoring, measurement and analysis of survey data and trends; communicates aggregate results and analysis to appropriate leadership.  (EF)

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

1. 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.  (EF)
2. Communicates innovative and best practices to hospital quality and patient safety departments and leadership.  (EF)
3. Identifies opportunities to align policy and procedure with regulatory/accreditation requirements.  (EF)
4. 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 (four year) degree in Nursing or other healthcare related field, Master¿s degree in healthcare or business-related field preferred.

¿ 5 years of experience in a hospital setting, preferably in patient care or quality.
¿ 3-5 years of experience in one or more of the following:  healthcare quality; patient safety; infection prevention and control; and/or health information management.
¿ 2 years of accreditation or regulatory activities in a hospital setting.

¿ Related quality, accreditation or health care certifications (such as CPHQ, ASQ, HACP, CSHA or RHIA certifications) are preferred.

¿ 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 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 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.
¿ Demonstrate an appreciation for cultural diversity and sensitivity.

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.

Company Profile

Since its founding in 1919, Houston Methodist Hospital has earned worldwide recognition. Houston Methodist Hospital is affiliated with the Weill Medical College of Cornell University and New York-Presbyterian Hospital, one of the nation's leading centers for medical education and research.  Houston Methodist is consistently ranked in U.S. News & World Report’s “Best Hospital” list and was recently named the number one hospital in Texas. FORTUNE magazine has placed Houston Methodist on its annual list of “100 Best Companies To Work For” since 2006.  Houston Methodist Hospital directs millions of research dollars into patient care and offers the latest innovations in medical, surgical and diagnostic techniques. With 1,119 licensed beds, 67 operating rooms and over 6,000 employees, Houston Methodist offers complete care for patients from around the world.

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