Regulatory and Accreditation Compliance Manager

Valley Medical Center - Renton, WA



POSITION TITLE: Regulatory and Accreditation Compliance Manager - Professional/ Exempt -  

JOB OVERVIEW: The Regulatory and Accreditation Compliance Manager is primarily responsible for coordinating organization-wide continuous readiness for Centers for Medicare and Medicaid Services (CMS), the Washington State Department of Health (DOH), and The Joint Commission (TJC) surveys including assessment, corrective action planning, auditing, and document production. In addition, the manager is responsible for supporting ongoing development, review and revision of standards (i.e. policies and procedures) in compliance with regulatory standards.

JOB ROLE: Refer to Administrative Partner job description.

AREA OF ASSIGNMENT: Outcomes Management

HOURS OF WORK: 8:00 am - 4:30 pm Monday - Friday with requirement for flexible hours

RESPONSIBLE TO: VP Quality Services


  • Bachelor’s degree in healthcare field, preferably nursing; masters preferred.
  • With nursing background, holds current license as a registered nurse in State of Washington.
  • Minimum 5 years clinical experience in acute hospital care with preference for medical-surgical nursing experience.
  • Experience in use of Electronic Health Record (EHR) preferred.
  • Minimum 1 year experience relevant to TJC accreditation preparation and survey coordination preferred.


  • Ability to relate to physicians and all employees including professional, technical and support staff regarding the application of standards to their work environment.
  • Knowledge and experience in the principles of teaching/learning including the ability to make formal presentations to physicians, leadership, and all staff.
  • Interpersonal skills necessary to interact cordially and effectively with members of the interdisciplinary team, including physicians and external health care professionals to achieve desired outcomes.
  • Ability to work collaboratively as a team member, acknowledging and valuing input of others.
  • Knowledge and experience in Performance Improvement (PI) tools, techniques and group facilitation preferred.
  • Communication skills including group facilitation and conflict management.
  • Ability to design and implement systems necessary to track projects and documents.
  • Ability to set priorities and meet deadlines and motivate others to assist in accomplishing goals.
  • Ability to attend to detail.
  • Fluency in English along with excellent verbal and written communication skills.
  • Ability to write legibly, spell correctly, and use accepted grammar.
  • Ability to function in a setting with numerous interruptions.
  • Ability to work independently without close supervision.
  • Basic proficiency in use of email and electronic calendars.
  • Solid working knowledge of and experience in use of MS Office Suite applications.
  • Basic proficiency in creating, saving, opening and attaching MS Word documents.
  • Thorough knowledge of Internet use as critical resource.
  • Ability to guide work of clerical support personnel.
  • Neat and well groomed appearance consistent with VMC dress code.


See Generic Job Description/Administrative Partner


  • Generally, work is performed in an interior office environment. Physical acumen is required to walk some distance within and between buildings on campus, climb stairs, stand for speaking engagements, and carry objects up to 25 pounds. Additionally, travel by car is required for responsibilities as they relate to the clinic network and UWMedicine Alliance.
  • Requires ability to coordinate/integrate standards across the organization.
  • Requires planning, organizing and working on multiple tasks at one time. On occasion, requires ability to work under pressure to complete assignments within a limited period of time to meet demands.
  • Requires ability to attend to detail as well as the organization-wide perspective.
  • Requires repetitive operation of computer and use of keyboard with accuracy and speed.
  • Requires ability to host surveyors graciously and "think on one’s feet" during the survey process.


A. Generic Job Functions: See Generic Job Description/Administrative Partner 

B. Unique Job Functions:

  • Demonstrate understanding of organizational structure and its application to project initiation and implementation.
  • Become considered and sought after as internal expert and key resource for regulatory and accreditation standards.
  • When practice changes are indicated, communicate changes to standards in timely manner to leaders; work with leaders to define necessary changes with mutually set time goals and desired outcomes.
  • Translate standards and evidence of compliance into practical behaviors or practice.
  • Develop knowledge of recommended practices from sources such as Patient Safety Foundation, IHI, professional associations, Life Safety code, etc. and incorporate into practice recommendations.
  • Negotiate formal and informal channels to champion change in the organization.
  • Implement methods to monitor and evaluate changes in operations to meet regulatory and accreditation standards.
  • Identify gaps in departments’ self-reported vs. actual compliance with state of Washington, federal and Joint Commission standards.
  • Analyze underlying causes/contribution to gaps and work with leaders to close gaps.
  • Apply previously learned information to new situations to solve problems.
  • Respond effectively to unexpected experiences.
  • Support the organization-wide (hospital and primary clinic network) commitment to continuous readiness for CMS, DOH and TJC licensing and accreditation surveys.
  • Maintain currency in CMS, DOH and TJC accreditation standards and communicate changes to appropriate individuals and bodies in a timely manner.
  • Review related literature (e.g. TJC Perspectives, The Joint Commission On-Line Newsletter and Sentinel Event Alerts) and disseminate relevant information to appropriate individuals on an ongoing basis.
  • Review and update the TJC Chapter Sponsor/Leader/Membership list and Continuous Readiness Calendar at least annually in collaboration with administrative leaders.
  • Coordinate regular status meetings with Chapter Leaders to conduct on-going assessments of survey readiness, assist with corrective action plans, implementation and evaluation.
  • Meet at least monthly in the year prior to anticipated Joint Commission survey.
  • Lead additional survey preparation meetings and activities related to continuous survey readiness as needed.
  • Coordinate "mock surveys" in accordance with evolving trends in survey methodology internally and with consultants.
  • Monitor and report state of survey readiness on a regular basis to Clinical Services Patient Safety, Quality & Risk Management Committee and Quality Improvement Council.
  • Present information and propose actions as needed to PCS Leadership Forum and Operations Council.
  • Monitor the VMC Quality Report on the TJC Web Site and reports concerns.
  • Direct questions to TJC for clarification of standards. Maintain record of communiqués.
  • Collaborate with Directors, Managers and Supervisors on their preparation of required documents in preparation for surveys.
  • Coordinate and submit the VMC/Primary Clinic Network Periodic Performance Review (PPR) annually in accordance with the TJC designated timeframe.
  • Monitor TJC website for notice of organization-wide accreditation survey and initiate notification tree.
  • Serve as liaison to CMS, DOH and TJC. Coordinate surveys and related activities when announced. Coordinate corrective action plans, evidence of standards compliance and measures of success and prepare responses to citations in a timely manner.
  • Support the development, ongoing review and revision of clinical services standards (policies, protocols, procedures, guidelines) in accordance with legal, professional, regulatory and accreditation standards and within appropriate timelines.
  • Facilitate VMC’s Adverse Event Management root cause analyses and provide on-going education and training to directors, managers, supervisors and staff as needed.
  • Provide to the Department of Health required information pertaining to mandatory reportable adverse patient care events.
  • Facilitate the regular pro-active risk assessment (FMECA) at least every 18 months.
  • Function as key resource for Accreditation Manager Plus on-line.
  • Perform other duties as assigned to meet patient/program needs including participation in orientation of new staff.

Job Type: Full-time


  • Nursing: 1 year (Preferred)
  • Evidence: 1 year (Preferred)
  • Regulations: 1 year (Preferred)
  • Administrative: 1 year (Preferred)


  • English (Preferred)