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Director Accreditation

Vancouver, WA, USA | Peace Health

  • Industry:
    Healthcare - Hospitals
  • Position Type:
  • Functions:
    Business Development
  • Experience:
    7-10 years
Job Description:
73 people have viewed this job

Leads the Clinical Excellence Leadership Team in providing ongoing status reports to leadership, attending Clinical Excellence Director meetings, assuring routine budget oversight for accreditation functions, regulatory team oversight and HR responsibilities.Participates in CE Network visits and provides leadership and oversight to direct reports.Assists other directors when needed for urgent PeaceHealth initiatives or patient care related priorities.

Serves as the system process owner for PeaceHealth Accreditation strategies, planning, programs and functions. Communicates and advises leadership on upcoming accreditation readiness processes, timelines, educational needs, plans and assessments. Oversees the Regulatory Team by providing leadership, coaching, planning, program development, tracer education etc.

Serves as content expert for accreditation requirements that pertain to PeaceHealth entities. Oversees and monitors accreditation requirements, reporting and accreditation standards and process changes. Provides reports and updates to senior leadership. Works with local leadership to develop strategies for accreditation readiness and ongoing compliance.

Develops annual Accreditation education plan for review by leadership.Works with leaders to align with PeaceHealth education standards, resources, tools and priorities. Assures all steps of education and implementation are completed. Meets with local leadership to assure their education needs are being met relating to caregiver and leadership knowledge of accreditation requirements.

Reviews and makes recommendations regarding regulatory structures and process at the system and local level to assure accreditation can be achieved and sustained. Works with leadership to remove barriers.Assures external content experts are utilized when needed to address and resolve network accreditation needs and priorities.

Assures core accreditation functions and process are in place for on-site accreditation surveys i.e. survey command center training and documentation, pre-survey information needed and educational resources, opening conference presentations as applicable, on-site survey draft schedules, escorts, tracking and follow-up forms and documentation.

Partners with System Director of Licensing to assure electronic tools, resources and processes are in place for initial internal scoring of accreditation standards, ongoing scoring to include actions plans and follow-up actions can be tracked and trended. Provides ongoing reports to system and local leadership relating to PeaceHealth accreditation areas of vulnerability and strengths and next steps.

In partnership with System VP, Clinical Excellence works to oversee and coordinate PeaceHealth Joint Commission accreditation Gap analysis surveys to include all planning, implementation and follow-up as well as these activities as they relate to mock surveys.Oversees coordination of follow-up reports, metrics and trending of these external surveys and assessments. Works with local leadership to assure structure and process owners are in place and have received appropriate education.

Serves as TJC Accreditation system representative and content expert, attending system committee and team meetings as needed.Develops sub-teams as needed to build and or coordinate action plans for specific areas of vulnerability relating to accreditation.

Conducts local accreditation readiness visits and skype meetings at all PeaceHealth accredited entities. Conducts focused visits for areas expecting accreditation visits and/or are working to submit follow-up action plans.Assures that regulatory consultants are engaged in this work and are clear about expectations.

Leads other PeaceHealth leaders to assure standard approach to accreditation issues/processes and ensures they are incorporated into strategic and operational plans.

Ensures appropriate tools and processes are available for tracking and trending of accreditation data, identifying opportunities for improvement system wide.

Oversees the regulatory consultants relating to Joint Commission Accreditation.For hospitals accredited by DNV assists the System Director with DNV regulatory readiness. Directs a team of subject matter expert clinical and technical staff to assure adherence to standard data definitions, data integrity practices, and data submission timelines to promote accurate, comparable, and actionable information.

Performs other duties as assigned.



Bachelor’s degree in a healthcare related field required. or a combination of education and professional experience that provides the caregiver with the requisite knowledge, skills and abilities to successfully perform the job with an agreement to obtain their master’s degree within 3 years of hire

Master’s degree preferred.

Nursing Candidates BSN or MSN required upon hire.


Minimum of 7 years of healthcare accreditation experience required.

Minimum of 5 years of management experience required.

Expert knowledge and skills in regulatory and accreditation standards obtained through a combination of education, training and experience.

Experience supporting healthcare institutions in meeting regulatory requirements and successfully reaching accreditation.

Advanced knowledge of Joint Commission Accreditation requirements.including but not limited to CMS Conditions of Participation for acute care and critical access hospitals.

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