Hospital - Accreditation Manager

UT Health San Antonio•San Antonio, TX

About The Position

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.

Requirements

Strong project management skills with the ability to multitask and prioritize competing demands.
Excellent communication and interpersonal skills, with the ability to collaborate effectively with diverse stakeholders.
Proficient knowledge of The Joint Commission and CMS standards and regulations.
Ability to develop and maintain a comprehensive accreditation plan and timeline.
Ability to analyze survey findings and recommendations to identify trends and areas for improvement.
Bachelor's degree in nursing or other healthcare-related field
Registered Nurse, Texas License

Nice To Haves

Master's degree preferred.

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.