Accreditation Specialist

3 weeks ago

Houston, United States CareerBuilder Full time

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.

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.
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.

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.

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.

QUALITY/SAFETY ESSENTIAL FUNCTIONS
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.

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.
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

WORK EXPERIENCE
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

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