Posted Jun 24 About Us Driscoll Children’s Hospital has been a leader in pediatric healthcare across South Texas since 1953. As a non-profit, freestanding children’s hospital, we serve a vast region of more than 45 counties, delivering compassionate, specialized care to infants, children, and adolescents.
At Driscoll, regulatory readiness and accreditation excellence are foundational to the care we provide. Our leadership team is committed to upholding the highest standards of compliance, safety, and quality—ensuring we remain survey-ready every day and continue to earn the trust of the families we serve.
Join an organization where your expertise in accreditation and regulatory affairs will directly support a culture of continuous improvement, operational integrity, and patient-centered excellence.
Position Details Title: Director of Accreditation & Regulatory Location: Corpus Christi, TX Schedule: Monday-Friday 8am-5pm Work Setting: On-site position (not remote or hybrid) Travel: 1-2 times a month, a few days at a time, to hospital in Edinburg, TX, and specialty clinics in Laredo, McAllen, Brownsville, and Victoria, TX, as needed.
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 the development, direction, and oversight of all organizational accreditation and regulatory programs
- Ensure ongoing compliance with The Joint Commission, state/federal regulations, and other applicable standards
- Update and maintain Joint Commission applications and complete the Focus Standard Assessment
- Develop and implement communication plans to inform staff and leadership of regulatory updates and changes
- Maintain and manage regulatory correspondence and documentation
- Conduct regular meetings with departments to review requirements and ensure continuous survey readiness
- Provide guidance and oversight to leadership and staff regarding compliance and regulatory expectations
- Collaborate with Decision Support in preparing and reviewing reports and data
- Serve as a mentor and provide leadership to direct reports and colleagues
- Ensure hospital-wide compliance with all accrediting and regulatory agencies
- Act as an improvement coach using the Model for Improvement and support performance improvement projects and FMEAs
- Lead regulatory-related educational initiatives such as New Hire Orientation, Error Prevention, and leadership training
- Travel to the RGV hospital and affiliated facilities as needed to support regional readiness
- Perform other duties as required to support the Center for Quality and Safety and broader organizational goals
Education & Experience
- Bachelor’s degree (B.A. or B.S.), Bachelor of Science in Nursing preferred. MS or MSN preferred.
- Leadership experience preferred.
- Minimum of 6 years clinical, quality or regulatory
Certificates, Licenses, Registrations
- Current Texas State RN license preferred.
- Certified Professional in Health Care Quality (CPHQ) or other relevant certification preferred.
- Active unrestricted Drivers License required.
Compensation & Benefits We offer competitive salaries, relocation assistance, along with a comprehensive benefits package that includes health insurance, retirement plans, and generous paid time off. We also provide ongoing professional development opportunities to support your career growth.
For a detailed overview of our benefits, visit: Driscoll Children's Hospital Employee Benefits.
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