Quality/Accreditation Specialist II

At Henry Ford Health, we're committed to advancing health and improving lives for the millions of people we serve across Michigan and around the world. As one of the nation's leading academic health systems, we provide a comprehensive continuum of care that includes primary and preventive services, specialty and complex care, virtual care, pharmacy, home health, eye care, health insurance, and more. With 12 hospitals and hundreds of ambulatory care locations, including former Ascension Southeast Michigan and Flint Region facilities, our growing network expands access to exceptional care in the communities we serve.

Headquartered in Detroit, Henry Ford Health is helping shape the future of healthcare through the transformative Future of Health: Detroit initiative, a $3 billion investment that is redefining our academic healthcare campus and advancing innovation, research, education, and community impact.

Our work is grounded in purpose, collaboration, and belonging. We empower team members to grow their careers, contribute innovative ideas, and make a meaningful difference every day. Whether you're caring for patients, supporting operations, conducting research, or driving new solutions, you'll be part of a team united by a shared mission: delivering exceptional care, advancing health outcomes, and building healthier communities for all.

Job Description

GENERAL SUMMARY:

As a Quality/Accreditation Specialist II, you'll play a pivotal role in shaping organizational excellence and regulatory success. Working with limited direction, you'll design and maintain comprehensive compliance frameworks that keep our organization survey-ready while driving continuous improvement. You'll serve as a trusted internal consultant, translating complex regulatory standards into actionable strategies and partnering with leadership and clinical teams to build a culture of compliance and quality.

PRINCIPAL DUTIES AND RESPONSIBILITIES:

Strategic Compliance Leadership

• Partner with corporate and business unit leadership to provide strategic direction and oversight of regulatory compliance across all accreditation bodies (The Joint Commission, DNV, CMS, and state/federal agencies)
• Design and maintain organizational infrastructure that ensures sustained compliance with evolving standards and regulations
• Develop and implement comprehensive readiness plans that position the organization for continuous compliance and successful survey outcomes

 

Consultation & Subject Matter Expertise

• Serve as the go-to consultant and educator for leadership teams, translating regulatory requirements into practical implementation strategies
• Interpret new regulations and provide expert guidance on compliance implications across the organization
• Lead resolution of complex compliance challenges by providing evidence-based strategies that meet regulatory intent
• Develop and review policies and procedures to ensure alignment with regulatory requirements

 

Readiness & Survey Management

• Coordinate agency-specific accreditation requirements and manage all aspects of on-site surveys and unannounced visits
• Provide strategic leadership and support during survey processes to ensure optimal outcomes
• Deliver routine reports to quality and governance committees highlighting compliance status, problem-prone areas, and action plans

 

Education & Performance Improvement

• Develop and deliver formal and informal education programs across the healthcare team and support staff, fostering a culture of regulatory readiness and safe practices
• Demonstrate expertise in process improvement methodologies (PDCA, FMEA, etc.) and provide consultation to clinical and administrative teams
• Direct, facilitate, and coordinate the design and implementation of clinical quality and patient safety initiatives at business unit, regional, and system-wide levels
• Provide project management support to clinical improvement initiatives and share best practices across the organization

 

Operational Excellence & Leadership

• Manage associates and activities to ensure continuous compliance operations and service delivery
• Demonstrate strong analytical and problem-solving skills to develop effective systems and processes
• Exhibit innovation and forward-thinking approaches to drive positive outcomes and organizational advancement
• Maintain professional composure and demonstrate leadership excellence under pressure while managing complex, competing priorities
• Communicate with clarity, discretion, and confidence to influence and negotiate results with internal customers and external stakeholders
• Act as an organizational ambassador with external agencies, building and maintaining strong professional relationships
• Leverage information technology to communicate effectively, manage knowledge, mitigate risk, and support data-driven decision-making

 

Continuous Learning & Professional Development

• Stay current with accreditation standards, federal and state regulations, compliance best practices, and organizational policies
• Model ethical, honest, and professional behavior in all interactions and decision-making

Qualifications

EDUCATION/EXPERIENCE REQUIRED:

• Bachelor’s degree in Nursing or healthcare related field required , Master’s degree in health care field preferred; RN preferred
• Minimum 5 years hospital experience required; clinical/operational experience preferred 
• Demonstrated knowledge of TJC, DNV, CMS Conditions of Participation required and familiarity with other accrediting, licensing and regulatory standards desirable.
• Evidence of continuing education in standards/regulations/training
• QI/PI Team member, lead or facilitator 1 – 3 years required
  • Scope: Broad Business unit/multidisciplinary team experience (working with several departments, and//or “deep” experience within one service line, value stream, etc)
  • Experience presenting to departmental, product line, and business unit leadership
• Knowledge of current healthcare issues and trends.
• Must meet or exceed core customer service responsibilities, standards and behaviors as outlined in the HFHS’ Customer Service Policy
• Must practice the customer skills as provided through on-going training and in-services.

Additional Information

PHYSICAL DEMANDS/WORKING CONDITIONS :

Normal office environment with minimal exposure to noise, dust, or extreme temperatures.