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Director, Accreditation

Benefits Eligibility (Employment Type):  Full-time benefits (32-40 hours per week)
Shift Type:  Day
Shift Length:  8 Hours
Primary Location (City):  Vancouver
State:  WA

PeaceHealth is seeking a Director, Accreditation for a 1.0 full time equivalent Exempt position. This position will be working Day shift with shift durations of 8 Hours.

Req ID: 194786



Serves as a leader within the Clinical Excellence Team overseeing Joint Commission Hospital Accreditation initiation, preparation, execution, follow-up and sustainment across PeaceHealth accredited entities. Guides the organization in achieving Joint Commission Accreditation status or an equivalent in accordance with 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.



  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. 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.
  7. 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. 
  8. 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.
  9. 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.
  10. 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.
  11. Leads other PeaceHealth leaders to assure standard approach to accreditation issues/processes and ensures they are incorporated into strategic and operational plans.
  12. Ensures appropriate tools and processes are available for tracking and trending of accreditation data, identifying opportunities for improvement system wide.
  13. 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. 
  14. 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.



  • Work requires fairly light physical exertion from up to 65% of the time.         
  • Ability to lift objects weighing 30 lbs. or less.          
  • Work is performed under normal working conditions with adequate lighting and ventilation.     
  • Job duties frequently require intense concentration and attention to detail (up to 65% of work time).

For full consideration of your skills and abilities, please attach a current resume with your application.


About Us

PeaceHealth, based in Vancouver, WA, is a not-for-profit Catholic health system employing approximately 16,000 caregivers, a multi-specialty medical group practice with more than 1,200 providers and 10 medical centers serving both urban and rural communities in Washington, Oregon, Alaska.  In 1890, the Sisters of St. Joseph of Peace founded what has become PeaceHealth. Today, the legacy of its founding Sisters continues with a spirit of respect, stewardship, collaboration and social justice in fulfilling its Mission. 


Get a feeling for the Spirit of PeaceHealth through this three-minute video, and visit us on Facebook or LinkedIn!  We offer competitive compensation, a robust benefits package and a collaborative, Mission-driven work environment!


To learn more please visit: jobs.peacehealth.org.  Questions? Review our Employment FAQ or email Recruitment@peacehealth.org. Please note this email does not accept resumes or applications.


Location: Vancouver, Director, Accreditation
Job Category:  Leadership 
Shift:  Day
Shift Length: 8 Hours
FTE: 1.0
Work Type:  Full Time
Hourly compensation starts at: $54.15, more depending on experience
Required Certifications/Licensure: n/a


PeaceHealth is committed to providing equal employment opportunities to all qualified job applicants and employees without regard to the following statuses: protected veteran, qualified individual with a disability, race, ethnicity, religion, gender, pregnancy, gender identity, national origin, age, genetic information, sexual orientation, or any other protected status in accordance with local, state, or federal laws.


The above information is intended to indicate the general nature and level of work performed by this position. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of caregivers assigned to this job.

Nearest Major Market: Portland Oregon
Nearest Secondary Market: Tacoma

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