Texas Health

Senior Director of Regulatory and Accreditation

Job ID
Regular Full-Time
Nursing Leadership
Regular Work Hours
Monday through Friday 8 a.m. to 5 p.m.




Texas Health Presbyterian Hospital Rockwall, recognized with the Gold Seal of Approval by the Joint Commission Accreditation of Healthcare Organizations, is the first full-service community hospital in Rockwall. THPHR offers 61 inpatient beds for acute medical and surgical needs, advanced medical technology and comprehensive services focused on quality patient care and safety close to home. Texas Health Rockwall is proud to be recognized as one of “Modern Healthcare’s Best Places to Work in Healthcare”.  

We are currently seeking a Senior Director of Regulatory and Accreditation who will succeed in taking Texas Health Presbyterian Rockwall to the next level in healthcare.  The Senior Director will be responsible for providing direction, leadership and coordination in all areas involving the Hospital's regulatory and accreditation plans and survey readiness.


Working with the Senior Leadership Team, under the direction of the Hospital President, the Senior Director will develop strategic plans and policies for improved quality throughout the Hospital and ensusre compliance with regulatory agencies. Deliverables include developing processes, policies and procedures for ongoing regulatory and accreditation preparedness and sustainment.  In addition, the Senior Director will have oversight for quality and risk management, patient safety and infection prevention.


Job Responsibilities




Monitor and supervise hospital compliance with The Joint Commission (TJC) and governmental agency's standards and requirements, acting as liaison during site reviews.

  • Implement Regulatory and Accreditation Plan, including formulation of related goals and targets
  • Support goals and targets through collaboration with Hospital Leadership and staff
  • Develop the facility's strategy and tactics for regulatory and accreditation preparation and successful surveys
  • Track progression and sustainment of processes and survey readiness
  • Implementation of processes which drive outcomes based, evidence based and cost-effective and safe practices in the facility setting
  • Oversight and facilitation for:
      o CMS Conditions of Participation
      o State Regulations and Licensure, liaise with State
      o TJC accreditation activities, liaise with TJC
      o Chest Pain/Stroke Certification programs and activities
      o National Health Safety Network (NHSN)
      o American Joint Replacement Registry (AJJR)
      o Leapfrog Hospital Safety Grade
      o Required submissions to CMS (QNET)
      o State Reportables



  • Develop and implement strategies to create and maintain a positive employee relations environment through transformational leadership
  • Recruit, orient and retain excellent staff
  • Supervise departmental staff, developing standards of performance, evaluating performance and initiating or recommending personnel actions
  • Mentor job-related growth of staff
  • Plan and execute in collaboration with Chief Medical Officer, Chief Nurse Executive and Chief Financial Officer the implementation of a comprehensive quality and safety management process
  • Develop and maintain KPI quality dashboard
  • Direct the preparation and maintenance of department reports and tracking of data for quality and safety initiatives, including preparation of reports for committees and executive management as required




  • Participate in and represent Texas Health Rockwall in system-wide quality/risk/patient safety committees and initiatives
  • Take initiative and coordinate with other departments to develop action plans for performance improvement and patient safety initiatives and risk reduction
  • Oversight Infection Prevention Program
  • Oversight and support processes and coordinate tactics that advance patient safety and performance improvement
  • Track, trend and monitor performance improvement outcomes and risk events
  • Work with other departments on hospital and system initiatives and support evidence-based best practices
  • Direct clinical outcomes program
  • Conduct initial investigation of events to begin information gathering process
  • Collaborate with staff/medical staff regarding management of event and communication with the patient/family
  • Communicate with the patient/family as necessary
  • Coordinate and facilitate meetings and development of action plans
  • Monitor progress and effectiveness of RCA Action Plans
  • Work to develop reports and results of action plans for Risk Management/Patient Safety Committee and Quality Committee






BSN required, Masters preferred
Five (5) years in clinical nursing and/or quality/outcomes, 3 years management and regulatory/accreditation experience preferred
Valid Texas RN license preferred
CPHQ preferred





Excellent verbal and written communication, negotiation and collaboration skills
Ability to collect, analyze and organize data
Team facilitation skills
Knowledge of regulatory and accreditation requirements
Ability to educate and motivate
Strong computer skills, including Microsoft Office applications




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