Accreditation Program Specialist
Hennepin County Medical Center - Minneapolis, MN

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Hennepin County Medical Center (HCMC) offers employment opportunities in a variety of settings, including our downtown Minneapolis hospital and clinics, and neighborhood clinics throughout the metro area. We are committed to creating a culturally competent and inclusive work and care environment for patients, families, and staff, and we encourage interested applicants with bilingual and bicultural skills to apply for positions at HCMC.

This position serves as an accreditation advisor for the hospital and its clinics under general direction and in partnership with the Accreditation Program Manager. This includes matters related to Joint Commission accreditation and CMS regulations including interpretation and education of new and existing standards, assessment of compliance, identification of opportunities for improvement, and actions required to maintain survey readiness.



Minimum Education/ Work

Bachelor’s degree in related healthcare field.
· Minimum of 3 years hospital and/or ambulatory experience.
· Or, an approved equivalent combination of education and experience.
· Knowledge of Joint Commission and CMS regulatory requirements.
· Analysis, communication, presentation and problem solving skills.
· Measurement, data gathering, and interpretation experience.
· Knowledge of patient care standards.
· Performance improvement principles and methods experience.
License / Certifications If incumbent is a Registered Nurse, possession of a valid license, or a permit to practice, issued by the State of Minnesota Board of Nursing is required.


1. Provides advice, support and coordination to achieve compliance with Joint Commission standards and CMS regulations.

a. Works in collaboration with the Accreditation Program Manager to advise clinical, operational,

and physician leaders of new standards, changing requirements, and critical topics.

b. Provides education to designated groups and /or functions in the organization including

presentations regarding specific topics as requested.

c. Conducts research on standards that require clarification and provides recommendations to the

relevant stakeholders.

2. Supports systems and structures that ensure continual readiness.

a. Designs and implements evaluation processes and tools in collaboration with the accreditation

program manager.

b. Conducts tracers and audits and reports findings.

c. Assists with preparation and delivery of manager education, including huddles and other venues.

d. Directs and/or participates in activities designed to improve performance in identified priority areas.

3. Designs, prepares, and distributes meaningful reports.

a. Designs and communicates relevant tracer and audit tools.

b. Collates tracer and audit results.


c. Prepares reports and/or presentations regarding findings and related activities.

d. Serves as a resource for Measures of Success and other metrics that require reporting and


4. Coordinates survey preparations in collaboration with accreditation manager and organizational


a. Participates in survey readiness planning.

b. Supports survey coordination requirements including scheduling, logistics, and documentation


c. Assists with required follow-up and formal responses related to survey findings.

5. Ensures that knowledge of standards, regulations, and methods remains current.

a. Maintains expertise and knowledge related to Joint Commission standards and CMS regulations.

b. Exhibits a working knowledge of other key regulatory standards, including OSHA, HIPAA, etc.

6. Participates on teams and committees as appropriate to support readiness and improvement efforts.

a. Serves as a member of the Joint Commission Steering Committee.

b. Participates in multi-disciplinary performance assessment and improvement teams as requested.

c. Works collaboratively with other leaders, departments and functions to ensure a systems approach to standard interpretation and implementation.

You've made the right choice in considering Hennepin County Medical Center for your employment! HCMC offers a wealth of opportunities for our ever-changing population and is a place you'll feel challenged, rewarded, and appreciated. We are dedicated to providing Equal Employment Opportunities for both current and future employees, who want to make an impact in our patients' lives. Thanks for choosing HCMC!

HCMC has the following Success Factors that apply to all our employees to ensure competency. They are: exhibits accountability, demonstrates ethics and trustworthiness, delivers customer service, embraces differences, uses resources wisely, communicates clearly, builds and strengthens relationships, champions change and seeks continuous growth. Employees must be able to demonstrate competency in these areas.

Please Note: external applicants selected for an interview with Hennepin County Medical Center must provide data for a Criminal Background Study. Offers of employment from Hennepin County Medical Center are conditional and contingent upon successful clearance of all background studies.

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