System Accreditation Specialist

At Houston Methodist the System Accreditation Specialist is responsible for providing systemwide 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 evidencebased best practices and standardization to enhance systemwide compliance.

PATIENT AGE GROUP(S) AND POPULATION(S) SERVED
Refer to departmental Scope of Service and Provision of Care plans as applicable for description of primary age groups and populations served by this job for the respective HM entity.

HOUSTON METHODIST EXPERIENCE EXPECTATIONS

• 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.

• Practices the Caring and Serving Model

• Delivers personalized service using HM Service Standards

• Provides for exceptional patient/customer experiences by following our Standards of Practice of always using Positive Language (AIDET Managing Up Key Words)

• Intentionally collaborates with other healthcare professionals involved in patients/customers or employees experiential journeys to ensure strong communication ease of access to information and a seamless experience

• Involves patients (customers) in shift/handoff reports by enabling their participation in their plan of care as applicable to the given job

• Actively supports the organizations vision fulfills the mission and abides by the I CARE values

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 policyprocedure electronic medical record system and entity committees or councils and presurvey survey and postsurvey activities.

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

• Prepares for and conducts department and systemwide 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 systemwide documents or materials with a regulatory or accreditation impact.

FINANCE ESSENTIAL FUNCTIONS

• Utilizes efficient and costeffective 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 internetbased 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 systemwide survey nonconformities between entities and corporate departments.

This job description is not intended to be allinclusive; 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

• Bachelors 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 bachelors 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

LICENSES AND CERTIFICATIONS REQUIRED

• N/A

LICENSES AND CERTIFICATIONS PREFERRED

• CPHQ Certified Professional in Healthcare Quality (NAHQ) Related quality accreditation or health care certifications OR
• CQA Certified Quality Auditor (ASQ) Related quality accreditation or health care certifications OR
• HACP Healthcare Accreditation Certification Program (CIHQ) Related quality accreditation or health care certifications OR
• CSHA Certification Specialist in Healthcare Accreditation Related quality accreditation or health care certifications OR
• RHIA Registered Health Information Administrator (AHIMA) Related quality accreditation or health care certifications

KNOWLEDGE SKILLS AND ABILITIES

• Demonstrates the skills and competencies necessary to safely perform the assigned job determined through ongoing 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 coworkers in a manner consistent with a customer service focus and application of positive language principles

• Knowledge of health care regulatory and accreditation requirements (such as Centers for Medicare/Medicaid Services/CMS CMS approved hospital accreditation organizations and State requirements)

• Proficient with intermediate computer level skills for document spreadsheet and graphic software (such as Microsoft Office Word Excel and PowerPoint)

• Expertise in quality or performance improvement tools and techniques process mapping and flow chart diagrams

• Ability to collect qualitative and quantitative data and information; analyze and apply data to problemsolving and improvement activities

• Selfdirected and able to work with minimal supervision; initiative to identify and utilize available internal and external resources; flexibility in work and assignments; adapts to change

• Proven time management skills and ability to meet deadlines and work under pressure; strong organizational skills and ability to prioritize multiple projects and tasks

• Strong interpersonal skills and 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 discreetly handle sensitive issues in a professional and confidential manner

SUPPLEMENTAL REQUIREMENTS

WORK ATTIRE

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

ONCALL*
*Note that employees may be required to be oncall during emergencies (ie. DIsaster Severe Weather Events etc) regardless of selection below.

• On Call* No

TRAVEL**
**Travel specifications may vary by department**

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

Houston Methodist (HM) is one of the nations leading health systems and academic medical centers. HM consists of eight hospitals: Houston Methodist Hospital its flagship academic hospital in the heart of the Texas Medical Center and seven community hospitals throughout the greater Houston metropolitan area. HM also includes an academic institute a comprehensive residency program a global business division numerous physician practices and several freestanding emergency rooms and outpatient facilities. Overall HM employs over 25000 employees. Houston Methodist is supported by a wide variety of business functions that operate at the system level to help enable clinical departments to provide the best patient care and service in a spiritual environment.

In 2019 Houston Methodist and its physicians treat more than 6333 international patients from more than 76 countries. Houston Methodist Global Health Care Services consulting and education divisions also provide advisory services and training and development to health care organizations around the world.