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Associate Director, Survey Readiness - Accreditation & Regulatory Affairs Education Communication

Houston, TX, USA | M.D. Anderson Cancer Center

  • Industry:
    Healthcare - Hospitals
  • Position Type:
  • Functions:
    General Management
    Regulatory Affairs
    PR & Communications
  • Experience:
    5-7 years
Job Description:
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The Associate Director of Survey Readiness has a comprehensive understanding of the role of accreditation and survey readiness and motivates staff at all levels of the institution to perform at the highest level to create a culture of continuous survey readiness.Collaborates with executive and faculty leadership to design and implement the educational programs for survey readiness for The Joint Commission (TJC), Center for Medicare and Medicaid Services (CMS), Texas Administrative Code, and other accreditation, regulatory, and certification bodies.Oversees the institutional accreditation and regulatory readiness education program collaborating with Nursing Education and other stakeholders.Ensures a measurable, outcome-focused, systematic approach to educate staff across the institution on accreditation and regulatory standards and to address educational needs identified in corrective action plans.Deliver ongoing targeted education and communication on hot topics and changes to accreditation and regulatory standards.

Key Functions

Accreditation and Regulatory Compliance

  • Ensure all educational requirements identified in institutional policies and CMS, TJC, and other regulatory body standards are met and performed on time (i.e., suicide, restraint, etc.)

  • Mentors Chapter Leaders in their role of supporting educational needs for their standard.

  • Develops trainings in collaboration with Chapter Leaders to meet the identified educational needs per corrective action plans.

  • Participates in the assessment of knowledge of standards for applicable staff across the institution and develops educational training to address gaps.

  • Ensures a measurable, outcome-focused, systematic approach to institutional accreditation and regulatory educational goals.

  • Coaches and mentors team members to ensure compliance with accreditation and regulatory compliance.

  • Communicates learner progress on educational initiatives on an ongoing basis to Accreditation and Survey Readiness and Chapter Leaders.

  • Demonstrates knowledge of policies and regulatory standards and suggests strategies for improving compliance.

  • Participates in Performance Improvement activities in Accreditation and Survey Readiness and other areas, as appropriate.

  • Leads/facilitates and participates in committees, task forces as assigned, using sound facilitation skills, executing actions to obtain desired outcomes by deadline dates, and evaluating the quality and quantity of outcomes.

Education Design, Implementation, and Evaluation

  • Designs sound educational offerings that:

  • Considers needs of the targeted audience

  • Outlines well-constructed educational objectives

  • Is organized and evidence-based

  • Utilizes adult learning principles and teaching methods that are congruent with objectives 

  • Incorporates strategies to address a variety of learning styles of participating individuals.

  • Demonstrates competency in the presentation of the educational offering, incorporating sound presentation standards.

  • Utilizes evaluation feedback to improve the quality of future educational offerings.

  • Identifies potential educational barriers and implements effective solutions.

  • Documents educational activities according to department standards.

Education and Communication

  • Serves as Program Administrator for the institutional accreditation and regulatory education program, including the Joint Commission Resources (JCR) Digital Learning Center and ensures the institution takes full advantage of these educational resources of monthly newsletters, courses on TJC standards and CMS conditions of participation with continuing education credit, and tracks institutional usage.

  • Organizes and delivers communication on accreditation, regulatory, and certification hot topics and changes to standards to all levels of the organization.

  • Manages Accreditation and Survey Readiness department intranet site.

  • Educates staff across the institution on how to use Accreditation Manager Plus (AMP), a software solution for managing a continuous compliance preparation process.

  • Demonstrates professional accountability by maintaining proficiency in assigned role and involvement in accreditation and regulatory professional organizations.Seeks opportunities to broaden professional perspective and knowledge.

  • Challenges status quo.

  • Embraces, communicates, and promotes effective change.

  • Actively participates in, assists and/or leads department, divisional and/or institutional improvement projects.

  • Promotes the strategic vision for continuous surveillance readiness for applicable accreditation, regulatory, and certification standards by building competency and an accountable and data-driven culture.


Required: Bachelor's degree in healthcare, education or related field.

Preferred: PhD in healthcare, education or related field.


Required: Six years of developing and leading institutional educational initiatives and projects.

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