Accreditation Specialist - Quality-Care Management

Overview

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.

Houston Methodist Standard

PATIENT AGE GROUP(S) AND POPULATION(S) SERVEDRefer 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 organization's vision, fulfills the mission and abides by the I CARE values

Responsibilities

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