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Director, Survey Readiness - Accreditation & Regulatory Affairs Nursing

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

  • Industry:
    Healthcare - Hospitals
  • Position Type:
  • Functions:
    General Management
    Regulatory Affairs
  • Experience:
    7-10 years
Job Description:
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The Director of Survey Readiness is responsible for planning, implementing, and directing activities that support the institution’s ability to achieve and sustain successful accreditation and regulatory compliance. Acts as a consultant on the interpretation of regulatory standards, including The Joint Commission (TJC), Centers for Medicare and Medicaid Services (CMS), and Texas Administrative Code; partners with institutional leaders to ensure a constant state of readiness; leads enterprise-wide tracer program in collaboration with other departments that conduct audits, tracers, and Zone Inspection Program (ZIP) rounds;and educates staff on accreditation standards supporting a culture of safe, reliable, quality care.

Key Functions

Enterprise-Wide Tracer Program and Survey Readiness

  • Develops and implements a centralized framework to accurately assess compliance with regulatory standards to include an institutional calendar of all audits, tracers, and ZIP rounds conducted by Accreditation and Survey Readiness and other departments.

  • Conducts ongoing risk assessments and mock surveys throughout the organization to identify areas of opportunities to better meet regulatory requirements and communicate the results to appropriate leadership.

  • Develops corrective action process to include plans for prioritized risks and designs and implements audits to evaluate the effectiveness of improvements and sustainability.

  • Manages activities to ensure constant readiness for institutional regulatory site visits and surveys.

Management of Clinical Accreditation Specialists (CAS) and Associated Projects

  • Manages the daily activities of the clinical accreditation specialists.

  • Mentors accreditation staff and accreditation liaisons on adoption and use of tools for patient/system tracers, risk assessments, data collection and analysis, and improvement methodology.

  • Assigns the clinical accreditation specialists (CAS) to work with the chapter leader and executive sponsors for TJC standards and CMS conditions of participation and TJC National Patient Safety Goals and oversees associated projects that CSAs are facilitating relating to their assigned areas.

Consultation and Expertise of Accreditation and Regulatory Standards

  • Maintains up-to-date knowledge and interpretation of TJC, CMS and Texas Administrative Code Standards.

  • Partners with Patient Safety and chapter leader and executive sponsors for TJC standards and National Patient Safety Goals and CMS conditions of participation on sustained compliance and other patient safety standards.

  • Provides consultative services to all levels of the organization on accreditation/regulatory issues, interpretation of standards and policies, and linkage to clinical and operational processes.


Required: Master's degree or higher in Nursing.


Required: Seven years of health care experience to include three years of accredidation or clinical compliance experience to include three years of supervisory or management capacity. Successful completion of the LEADing Self Accelerate program may substitute for one year of required supervisory or management experience.


Required: Current State of Texas Professional Nursing license (RN) or Written authorization from the Texas Board of Nursing to function as an Advanced Practice Registered Nurse.

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