RN Accreditation Coordinator

The Polyclinic Seattle , WA 98113

Posted 3 months ago

Hours: Full Time; Monday - Friday; TBD

Location: The Polyclinic 1145 Broadway

Position Summary:

The RN Accreditation Coordinator develops, implements, and coordinates activities to ensure continuous compliance with Accreditation, State and Federal regulations and other external certification programs for the Accredited and Licensed Polyclinic Facilities.


  • Serve as a resource for interpretation of regulatory, accreditation and certification standards (as applicable)

  • Interpret and applies relevant standards to department/facility clinical and operational practices as well as to policies and procedures.

  • Collaborate with clinical managers to develop, implement, review, and update departmental policies and procedures

  • Develop and implement a Quality Assurance Performance Improvement (QAPI) plan in conjunction with the leadership team

  • Maintain oversight and documentation of QAPI studies, including audit activity

  • Compile and complete Mandatory Quality Reporting

  • Perform concurrent and closed medical record review audits to assist in determining compliance with accreditation and regulatory requirements

  • Conduct patient and system tracers in patient care areas through observation of practice

  • Collect, analyze and report data in support of continuous readiness activities

  • Disseminate the results of audits and surveillance results as needed

  • Assist in assuring accuracy and timeliness in submission of corrective action plans to internal stakeholders and external agencies

  • Design and implement survey management plans

  • Develop and deliver staff and leadership education related to regulatory and accreditation standards and processes

  • Track, investigate, filter, and trend reportable events and other facility data

  • Develop combined quality, safety, and infection control reports

  • Partner with other departments and services for in-house educational initiatives, including those related to regulatory compliance with Washington State Department of Health (DOH), OSHA, as well as community standards

  • Work in coordination with Polyclinic Employee Health and Safety (EHS) department to ensure Occupational Safety and Health Administration (OSHA), Washington Industrial Safety and Health Administration (WISHA) and Department of Ecology (DOE) compliance as well as other employee health as safety requirements (annual training, education and testing, file and record maintenance, etc.)

  • Develop, coordinate, and implement the infection prevention and control program including data collection and audits and make recommendations regarding results of surveillance activities to ensure ongoing compliance with national and/or professional standards


  • Co-Chair the QAPI group

  • Conduct routine mock surveys and surveillance activities

  • Roll up and report Quality data i.e. Incident/Accident/Grievance/Patient Satisfaction data to the Quality Committee

  • Collaborate with Risk management as well as Quality and Patient Safety to ensure Annual Risk Assessments are completed and aligned with Quality plans

  • Work on special projects as assigned

  • Perform other duties as assigned



  • Bachelor's Degree in Nursing


  • Current Washington State RN license


  • 3 to 5 years clinical experience

  • Endoscopy/operating room experience preferred

  • Previous experience with Accreditation/Regulatory Surveys preferred


  • Critical thinking/problem-solving skills

  • Ability to multitask

  • Outstanding verbal and written communication skills

  • Analytical skills

  • Ability to effectively engage medical staff, managers, employees, and others

  • Committee/workgroup facilitation

  • Computer and data management skills including Microsoft Word, Excel, and PowerPoint

  • Process improvement

  • Efficient and effective organizational skills with fine attention to detail

  • Capability of working interdependently with a variety of individuals and teams in a highly integrated work environment while maintaining professionalism at all times

  • Ability to triage and prioritize ever-changing quality functions and priorities

  • Demonstrated skills in information management principles, data analysis interpretation and continuous quality improvement tools/methodologies

Additional requirements:

  • Requires flexible hours of work

  • Must be able to establish and maintain effective working relationships with managers and peers

  • Efficient work in a fast-paced, ever-changing/evolving department

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RN Accreditation Coordinator

The Polyclinic