Director of Accreditation & Regulatory
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Join to apply for the Director of Accreditation & Regulatory role at Driscoll Children's Hospital

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Join to apply for the Director of Accreditation & Regulatory role at Driscoll Children's Hospital

Where compassion meets innovation and technology and our employees are family.Thank you for your interest in joining our team! Please review the job information below.The Director of Accreditation & Regulatory is responsible for the strategic oversight, development, and implementation of all accreditation and regulatory initiatives across the organization. This role ensures continuous compliance with applicable standards and regulatory requirements, with a primary focus on maintaining Joint Commission accreditation. The Director collaborates closely with departments and senior leadership to drive organizational readiness, support performance improvement, and ensure a culture of quality and compliance.The Director will also oversee the preparation of regulatory documentation, including the Focus Standards Assessment, and lead the organization's response to accreditation surveys and regulatory changes.Key Responsibilities:

• Lead and manage accreditation and regulatory activities across the hospital.
• Oversee Joint Commission readiness, including application updates and Focus Standard Assessments.
• Collaborate with all departments to ensure understanding and adherence to regulatory standards.
• Keep leadership and staff informed of regulatory updates and changes.
• Provide mentorship and guidance to staff, directors, and departmental leaders.
• Lead or assist in process improvement projects using PDSA and other quality models.
• Ensure accuracy in departmental scorecards, reports, and data in collaboration with Decision Support.
• Maintain documentation, correspondence, and records related to regulatory compliance.

Education & Licensure:

• Bachelor of Science in Nursing required; Master of Science in Nursing preferred.
• Current Texas RN license preferred.

Experience:

• Minimum of six (6) years of acute care hospital-based clinical experience (1–2 years in intensive care preferred).
• Leadership experience in a healthcare setting strongly preferred.

Certifications:

• Certified Professional in Healthcare Quality (CPHQ) preferred.

Seniority level

• Seniority levelDirector

Employment type

• Employment typeFull-time

Job function

• Job functionLegal
• IndustriesHospitals and Health Care

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