Director of Accreditation Readiness & Patient Safety - FT - Days

Directors and Executives (Nursing and Non-Nursing) Edinburg, Texas


Position at DHR Health


The Director of Accreditation and Patient Safety is responsible for leadership oversight in planning, administering and monitoring all aspects of regulatory compliance, survey readiness and patient safety with hospital regulatory standards; and leads and coordinates regulatory compliance, survey readiness and patient safety initiatives to promote awareness, education, and assure continuous assessment and compliance with all regulatory, state, CMS, and The Joint Commission standards relating to hospital accreditation.


  • High School/GED required
  • Bachelor's Degree in Nursing; Master's degree preferred.
  • Registered Nurse with current Texas license required
  • Excellent customer service skills.
  • Computer skills required with knowledge of Microsoft Office suite.
  • Good written and verbal communication skills required.
  • Bilingual – English/Spanish.



  • Two (2) years’ experience with quality and process improvement methodologies, statistical analysis, and data base management preferred.
  • A minimum of two years’ experience in an influential role within a hospital or health care organization
  • Strong knowledge of CMS Conditions of Participation, Federal and State Regulations, and The Joint Commission Accreditation standards.
  • Current working knowledge of ethical, regulatory and accreditation requirements and ability to interpret into sound clinical practice and policy.
  • Demonstrated strong people skills, and oral and written communication skills to effectively deliver presentations and express enter-personal skills necessary to establish and maintain effective working relationships across the Health System.
  • Demonstrated ability to problem solve, think critically and creatively, and provide leadership through a consultative role.



  • Promotes the facility mission, vision and values by effectively communicating them to others. Considers mission, vision and values in developing services, standards and practices.
  • Support hospital wide implementation of quality regulatory standards. Act as facility expert for regulatory standards and patient safety expectations to hospital staff and medical staff.
  • Monitor/Evaluate staff with regulatory standards, requirements, processes, policies and guidelines. 
  • Evaluate shortcomings and identify targets for improvement.
  • Active participation/service on facility nursing and interdisciplinary committees. Maintain compliance with applicable regulatory and accrediting agency standards.
  • Responsible for Identifying gaps for organizational regulatory and compliance to determine clinical regulatory and compliance improvement opportunities within DHR-RMF Departments as applicable.
  • Works collaboratively with Senior Leadership, Clinical and Medical Staff leadership, Ethics and Compliance Officer, Safety Officer, Director of Risk Management, and Director of Performance Improvement.
  • Develops and implements short-term strategies that have long-term impact through the achievement of accreditations throughout the organization (at various position units). Translates accreditation, regulatory, and compliance strategies and procedures into actionable plans.
  • Working with the Quality Director, develop and implement an effective compliance program including the following:
    • Creating compliance policies based on applicable laws, regulations, rules, guidance and industry standards.
    • Develop effective training program for the corporate compliance program.
    • Designing an auditing and monitoring program for compliance program.
    • Oversee creation of tracking and reporting of data required by DHR leadership
  • Other duties as assigned