Accreditation Manager Multispecialty & Research Hospital

UT Health San Antonio
US - Texas - Sugar Land
June 28, 2024
Management

Job Summary

Reporting to the Senior Director of Quality, Safety and Accreditation, the Hospital Accreditation Manager, will be a key member of the Quality and Safety team working with senior and executive leaders. This is a critical role to ensure that our hospital achieves and maintains compliance with the standards set forth by accrediting bodies such as The Joint Commission and the Centers for Medicare & Medicaid Services (CMS). The accreditation manager serves as an organizational leader, consultant, and subject matter expert to lead and coordinate the accreditation process, manage surveys, and collaborate with various departments to develop and implement policies, procedures and practices that uphold quality and safety standards. This position requires a deep understanding of accreditation requirements, excellent organizational skills, and the ability to lead and educate staff on compliance measures.

Responsibilities

Lead the hospital's accreditation efforts by staying abreast of evolving standards set by The Joint Commission, CMS, and other accrediting and certifying agencies.
Ensure hospital policies, procedures, and practices align with accreditation standards.
Coordinate and manage all aspects of accreditation surveys, including preparation, scheduling, and follow-up activities.
Serve as the primary point of contact during surveys, guiding surveyors and providing necessary documentation and information.
Conduct mock surveys and readiness assessments to identify areas for improvement and ensure survey readiness.
Collaborate with department heads and stakeholders to develop and revise policies and procedures to meet accreditation standards.
Facilitate training sessions to educate staff on new or updated policies and ensure compliance with accreditation requirements.
Implement quality improvement initiatives to address survey deficiencies and enhance overall compliance.
Monitor and evaluate the effectiveness of quality improvement efforts and adjust strategies as needed.
Maintain accurate and up-to-date documentation related to accreditation activities, survey results, and compliance efforts.
Prepare and submit reports to hospital leadership and accrediting bodies as required.

Qualifications

EDUCATION:

Bachelor's degree in a healthcare-related field, nursing, or a related field.
Master's degree preferred.

EXPERIENCE:

Five (5) years of hospital accreditation experience is required
Two (2) or more years of leadership and management experience preferred

CERTIFICATION/LICENSURE:

Hospital Accreditation Certification (HACP or CJCP) preferred
Certified Professional in Healthcare Quality (CPHQ) preferred

Associated topics:
captain, executive team leader, fire captain, fire chief, fire marshal, lieutenant, planning operations, senior manager, sergeant, shift supervisor

Read the full job description and apply online on the recuiter's web-site

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