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Director, Accreditation & Regulatory

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Job ID: 42780
Location: Vancouver, WA
Work Type: Full Time
Shift: Day
Shift Length: 8 Hours
FTE: 1.00
Benefit Eligibility: Full-time benefits

Job Description


PeaceHealth is seeking a Director Accreditation & Regulatory for a Full Time, Day position.

Must be fully vaccinated for COVID-19 including 2 doses of a 2-dose series or 1 dose of a 1-dose series plus 14 days beyond the final dose prior to start date.

Annual compensation is $119,475.20 - $179,212.80; hiring rate dependent on qualifications and professional experience.

Serves as a leader within the Clinical Excellence (CE) team assisting with oversight and managing daily operations of the Accreditation and Regulatory Program and functions. Works closely with the System Director to guide the organization in assuring compliance with regulatory requirements with alignment of leadership priorities and strategies. Works with system and local leadership to continue and/or develop hospital wide accreditation structures, programs and processes which result in compliance with Hospital Acute Care and Critical Access accreditation requirements. Assures tools, structures and processes are in place to conduct ongoing assessments of accreditation readiness as applicable in entities outside of PeaceHealth hospitals who are accredited and/or plans to have accreditation status in the future.


  • Works closely with the Clinical Excellence Leadership Team in communicating regulatory preparation work and providing ongoing status reports related to regulatory and accreditation to leadership. Assists other directors when needed for urgent PeaceHealth initiatives relating to regulatory and accreditation or patient care related priorities.
  • Performs routine administrative roles supporting the System Director relating to attending CE Leadership meetings, assisting with budget oversight, assuring HR functions and process are carried out according to PeaceHealth policies and in accordance with required deadlines.
  • 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.
  • At the Direction of the System Director oversee the Regulatory team staffing to meet the needs of the organization. Oversee onboarding, performance assessments and required and recommended education. Serves as key regulatory leader both at the System, network and local level. Develops and/or plans and carries out regulatory monitoring tools, rounds, tracers and local regulatory program structures and processes to assure compliance with regulatory requirements. Leads the local regulatory teams in assuring survey preparation process, materials, command centers, resources and other supporting functions are in place and current relating to ongoing regulatory readiness. Joins the System Director of Regulatory in leading hospital mock surveys, coordinating any external visits with consultants and supporting the local teams during actual surveys as needed.
  • Along with the System Director, 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 the System Director of Regulatory who shall finalize and report to senior leadership at the local and system level. Works with local leadership to identify, develop and implement processes, methods and strategies necessary for achieving ongoing regulatory readiness and ongoing compliance.
  • Partners with the System Director to develop an annual regulatory 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.
  • 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 and System Director, works to oversee and coordinate PeaceHealth Joint Commission accreditation Gap analysis surveys and/or planning for actual surveys as directed by Sr. Leadership. 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. Addresses and communicate barriers as they are identified.
  • Along with the System Director, conducts local accreditation readiness visits and remote 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 the 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.
  • 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.
  • Strong knowledge and experience in quality improvement principles. Some Lean experience preferred.
  • Experience managing complex programs and projects, specifically with a focus on regulatory and accreditation requirements and completion of quality improvement projects with desired outcomes.
  • Experience and knowledge in use of administrative data quality, data specifications and statistical validity.
  • Experience using, teaching and applying quality management tools


  • Certified Joint Commission Professional (CJCP) required or completion of certification within one year of employment.


  • Ability to deliver financial results for areas of accountability.
  • Skill in team leadership, promotion, facilitation, project implementation, effective data interpretation, employee relations
  • Excellent verbal and written communication skills
  • Project management skills. Ability to prioritize and manage multiple projects in a highly matrixed and disbursed organization

For full consideration of your skills and abilities, please attach a current resume with your application. EEO Affirmative Action Employer/Vets/Disabled in accordance with applicable local, state, or federal laws.

See how PeaceHealth is committed to Inclusivity, Respect for Diversity and Cultural Humility.

PeaceHealth is committed to the overall wellbeing of our caregivers: physical, emotional, financial, social, and spiritual. We offer caregivers a competitive and comprehensive total rewards package. Some of the many benefits included in this package are full medical/dental/vision coverage; 403b retirement plan employer base and matching contributions; paid time off; employer-paid life and disability insurance with additional buyup coverage options; tuition and continuing education reimbursement; wellness benefits, and expanded EAP and mental health program.

For full consideration of your skills and abilities, please attach a current resume with your application. EEO Affirmative Action Employer/Vets/Disabled in accordance with applicable local, state, or federal laws. For any questions, please feel free to contact Kirk H Hunt, Executive Recruiter [email protected]

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