Accreditation Program Coordinator Job

Children's Health - General Careers

Job Number: 51463

Location: Dallas, TX

Date Posted: 2-22-2017


Position Summary

The Accreditation Program Coordinator manages, facilitates and coordinates accreditation and regulatory readiness activities. The primary focus is to support the Accreditation Department and director by assisting in the planning and implementation in accordance with established policy and procedure standards, applicable regulatory requirements and hospital strategic objectives.

Essential Duties and Responsibilities

  • Manages, facilitates and coordinates accreditation and regulatory readiness program activities in collaboration with department members, department director and key senior leadership members.
  • Maintains ongoing program evaluation through maintenance of accreditation program dashboards. These dashboards include, but are not limited to, Periodic Performance Review, National Patient Safety Goals, and Measurable Joint Commission Standards.
  • Maintains a comprehensive rotational auditing process in collaboration with department director. Assesses and recognizes self-development needs. Seeks out resources or experiences which promote professional growth. Participates in mock or actual survey readiness activities.
  • Coordinates a master program of activities calendar in collaboration with department members regarding development of program materials. Develops a monthly, departmental calendar in collaboration with department members on key education programs or required regulatory activities. Communicates program status and evaluation results/trends to department director on an ongoing basis.
  • Communicates with other departments regarding program offerings on an ongoing basis. Maintains files in accordance with requirements from regulatory agencies. Participates in the evaluation of the cost effectiveness of Accreditation and Regulatory Readiness program.
  • Maintains appointment calendar for department director as back up. Represents the department within various committees, as requested by department director.



  • Four-year Bachelor's degree in Nursing, Business or equivalent education and/or professional experience


  • 2-5 years’ experience in health care, required

Specific knowledge, skills and abilities

  • Maintain effectiveness when experiencing major changes in work responsibilities or environment; adjust effectively to work within new work structures, processes, requirements, or cultures.
  • Use appropriate interpersonal styles to establish effective relationships with customers and internal partners; interact with others in a way that promotes openness and trust and gives them confidence in one's intentions.
  • Meet patient and patient family needs; take responsibility for a patient's safety, satisfaction, and clinical outcomes; use appropriate interpersonal techniques to resolve difficult patient situations and regain patient confidence.
  • Ensure that the customer perspective is a driving force behind business decisions and activities; craft and implement service practices that meet customers' and own organization's needs.
  • Develop and use collaborative relationships to facilitate the accomplishment of work goals.
  • Identify and understand issues, problems, and opportunities; compare data from different sources to draw conclusions; use effective approaches for choosing a course of action or developing appropriate solutions; take action that is consistent with available facts, constraints, and probable consequences.
  • Take prompt action to accomplish objectives; take action to achieve goals beyond what is required; be proactive.
  • Deal effectively with others in an antagonistic situation; use appropriate interpersonal styles and methods to reduce tension or conflict between two or more people.
  • Effectively manage one's time and resources to ensure that work is completed efficiently.
  • Accomplish tasks by considering all areas involved, no matter how small; showing concern for all aspects of the job; accurately checking processes and tasks; being watchful over a period of time.
  • Set high standards of performance for self and others; assume responsibility and accountability for successfully completing assignments or tasks; self impose standards of excellence rather than having standards imposed.
  • Assimilate and apply new job-related information in a timely manner.
  • Clearly convey information and ideas through a variety of media to individuals or groups in a manner that engages the audience and helps them understand and retain the message.

Physical demands

  • Sedentary - Exerting up to 10lbs. occasionally or negligible weights frequently; sitting most of the time.

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