Director of System Accreditation & Medical Staff Services

Position: Director of System Accreditation & Medical Staff Services

Job ID: 157088

Location: US-TX-Houston


Talent Area: Professional - Non-Clinical

Full/Part Time: Full-Time

Regular/Temporary: Regular

Shift: 8a - 5p

About Texas Children's Hospital

Since 1954, Texas Children’s has been leading the charge in patient care, education and research to accelerate health care for children and women around the world. When you love what you do, it truly shows in the smiles of our patient families, employees and our numerous accolades such as being consistently ranked as the best children’s hospital in Texas, and among the top in the nation by U.S.News & World Report as well as recognition from Houston Business Journal as one of this city’s Best Places to Work for ten consecutive years.   Texas Children’s comprehensive health care network includes our primary hospital in the Texas Medical Center with expertise in over 40 pediatric subspecialties; the Jan and Dan Duncan Neurological Research Institute (NRI); the Feigin Center for pediatric research; Texas Children’s Pavilion for Women, a comprehensive obstetrics/gynecology facility focusing on high-risk births; Texas Children’s Hospital West Campus, a community hospital in suburban West Houston; and Texas Children’s Hospital The Woodlands, a second community hospital opening in 2017. We have also created the nation’s first HMO for children, established the largest pediatric primary care network in the country and a global health program that is channeling care to children and women all over the world. Texas Children’s Hospital is also academically affiliated with Baylor College of Medicine, one of the largest, most diverse and successful pediatric programs in the nation.   To join our community of 13,000 dedicated team members, visit for career opportunities. You can also learn more about our amazing culture at


We are searching for a Director of System Accreditation & Medical Staff Services -- someone who works well in a fast-paced setting. In this position, you will provide leadership in meeting operational and fiscal objectives as they relate to regulatory process improvement activities which include inpatient and outpatient accredited sites with primary focus CMS Conditions of Participation (CoPs) and The Joint Commission (TJC) standards of optimizing quality and safety processes. You will also provide leadership for Medical Staff governance, committee oversight, Graduate Medical Education and Continuing Education.


Think you’ve got what it takes?

Responsibilities :

  • Drives the establishment of key performance indicators for all regulatory metrics. Develops, monitors, and reports regulatory measures
  • Develops and maintains systems and relationships to ensure services provided by the department are cost effective and serve the needs of all customers
  • Develops and maintains an environment that promotes a "customer service" attitude and facilitates process improvement efforts
  • Reviews and modifies the departmental strategic plan, as well as develops and implements new continuous improvement initiatives appropriate to the current business environment
  • Deploys rapid cycle process improvements, including Plan Do Study Act (PDSA), as the primary driver for continuous improvement and integrates other project management tools as needed
  • Directs the activities in the department related to the hiring, professional development, general competency, promotion, performance appraisal and disciplinary action of supervised staff


  • Bachelor’s degree in nursing, pharmacy, healthcare administration, or a related clinical degree required
  • Master’s degree in nursing, MBA, MPH or related preferred
  • 5 years clinical healthcare experience including 5 years of quality, process improvement and/or change management experience required

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