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Accreditation Specialist RN

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POST DATE 8/31/2016
END DATE 10/14/2016

Methodist Nassau Bay, TX

Nassau Bay, TX
AJE Ref #
Job Classification
Full Time
Job Type
Company Ref #
Entry Level (0 - 2 years)
Bachelors Degree


Job Summary

The Accreditation Specialist 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 HM St. John Hospital as a resource, mentor, and educator for regulatory, accreditation and certification programs; and works across the hospital to assess, measure, and report ongoing compliance with standards, promote evidence-based best practices, and standardize common survey processes.


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 Houston Methodist 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.

1. 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.
2. 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.
3. 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.

1. Provides ongoing support and guidance to senior and department hospital leaders to comply with regulatory, accreditation and certification requirements, including facilitating and leading teams and committee participation.
2. Coordinates on-site survey response and actions.
3. Communicates survey findings to hospital leadership.
4. Provides education and training related to regulatory, accreditation, and disease-specific certification requirements.
5. Prepares for and conducts department and hospital meetings to include agenda, applicable reports and materials, minutes (or summary of previous meeting discussion and actions), and related data for applicable performance measures.

1. Facilitates, supports and participates in pre, post, and on-site survey activities for accreditation, regulatory and disease-specific certification programs.
2. Facilitates resolution of survey nonconformities through monitoring the progress of corrective action plans on an ongoing basis.
3. 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.
4. Participates in 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.
5. Conducts ongoing monitoring, measurement and analysis of survey data and trends; communicates aggregate results and analysis to appropriate hospital department staff and leadership.

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.

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.
2. Communicates innovative and best practices to hospital quality and patient safety departments and leadership.
3. 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 (4-year) degree in Nursing or other related health care field.


* 3 years of experience in a hospital setting, preferably in patient care or quality.

* 1-3 years 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.

Related quality, accreditation or health care certifications (such as CPHQ, ASQ, HACP, SCHA or RHIA certifications) 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, DNVGL NIAHO/ISO 9001 and/or State requirements).

* Working knowledge of quality/performance improvement concepts, 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


At Houston Methodist, Leading Medicine is more than a description of what we do; it's who we are. We take our responsibility as Houston's premier health care system seriously, and with a national reputation for excellence in patient care, innovation and research, we hold ourselves and the careers we build to a higher standard. Our culture is diverse, dynamic and challenging. We believe in our I Care Values and conduct ourselves with Integrity, Compassion, Accountability, Respect for others and a commitment to Excellence. Discover the difference for yourself and join Houston Methodist.

Company Size:
5,001-10,000 Employees
Health Care
Social Media:
8100 Greenbriar
Houston, TX 77030

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