System Accreditation Specialist - Houston Methodist Hospital : Job Details

Note: Candidates with background in neonatal care programs and experience with State neonatal and maternal designation programs strongly encouraged to apply.

At Houston Methodist, the System Accreditation Specialist is responsible for providing system-wide consultative services to Houston Methodist entities that foster a standardized, unified perspective and understanding of accreditation and regulatory program requirements and activities. The position serves as a consultant, resource, mentor, and educator for regulatory and accreditation programs; works across the system to assess, measure, and report compliance with standards; and develops, implements and evaluates strategies to promote the use of evidence-based best practices and standardization to enhance system-wide compliance.

PEOPLE ESSENTIAL FUNCTIONS

• Collaborates and effectively communicates with a wide variety of disciplines, including all levels of staff, leadership and medical staff across the system to facilitate, evaluate, improve, and sustain regulatory and accreditation compliance.

SERVICE ESSENTIAL FUNCTIONS

• Reviews regulatory and accreditation resources on an ongoing basis to identify updates (CMS Conditions of Participation, State Hospital Licensing Rules and other relevant accreditation and certification program standards); communicates updates to hospital entities and relevant corporate departments.

• Facilitates communication and assessment of needs for processes and practices to comply with new or revised requirements.

• Provides consultative guidance, interpretation and direction related to regulatory and accreditation requirements for policy-procedure, electronic medical record, system and entity committees or councils, and pre-survey, survey and post-survey activities.

• Develops, conducts and evaluates education and training programs or other resources related to regulatory and accreditation requirements.

• Prepares for and conducts department and system-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.

QUALITY/SAFETY ESSENTIAL FUNCTIONS

• Develops, implements and evaluates strategies to meet and sustain regulatory and accreditation compliance; promotes continual improvement in compliance with standards, including ISO 9001 Quality Management System.

• Conducts internal surveys across the HM system using ISO 9001 process audit tools and techniques to evaluate the effectiveness of actions taken for previous survey findings, perform a risk assessment of survey findings from across the system, and/or identify potential risks related to new or revised requirements; provides report of survey findings, relevant standard references and recommendations for improvement.

• Communicates survey findings to relevant corporate department and entity stakeholders; maintains a library of current and past survey reports.

• Collects, aggregates, and analyzes survey data and trends across the system; identifies opportunities for improvement; reports aggregate results and analysis through appropriate entity and system venues.

• Coordinates content development and implementation of system-wide documents or materials with a regulatory or accreditation impact.

FINANCE ESSENTIAL FUNCTIONS

• Utilizes efficient and cost-effective work practices with department resources and supplies; provides recommendations to reduce expenses; enters reimbursable business expenses in a timely manner.

GROWTH/INNOVATION ESSENTIAL FUNCTIONS

• Remains current with regulatory and accreditation program requirements and best practices through available resources such as conferences, internet-based learning, review and research of specific program materials, and/or professional journals.

• Identifies and participates in opportunities to standardize and align practices across the system (such as policy and procedure, entity processes, patient and other organizational materials); shares innovative and best practices with entity Quality and Patient safety leaders, system councils or committees, and relevant corporate departments.

• Facilitates resolution of system-wide survey nonconformities between entities and corporate departments.

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 healthcare related field; may consider HM employee with Registered Nurse license and four additional years of directly related experience (in addition to the minimum experience requirements listed below) in lieu of bachelor's degree

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 hospital setting; patient safety; infection prevention and control; and/or health information management