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Accreditation Coordinator





Position Type:


Start Date:

2021-08-26 14:00

Closing Date:

2021-10-15 17:00


Accreditation Coordinator

Temporary (18 months) position
Internal / External Posting

Position Description:
Reporting to the Chief Executive Officer and working closely with all members of the hospital Leadership team, the Accreditation Coordinator is responsible for overseeing the process of achieving compliance with the Accreditation Canada Qmentum Program.

Accreditation Preparation:
  • Identifying parties involved in the Accreditation process, and whose partnership will be necessary to achieve superior results.
  • Collects data on the state of the hospital, by means of: Surveys, interviews, consultation sessions, Reviewing past Accreditation results, Policy / practice gap analysis, "mock"/simulated Accreditation exercises, and other appropriate methods.
  • Acquires access to the hospital's Accreditation portal and reviews: Qmentum standards and expectations, Required Organizational Practices (ROPs), reports from past Accreditations
  • Developing and establishing benchmarks to measure the hospital's performance vs. Accreditation standards.
  • Consulting with stakeholders regarding their roles and accountabilities in the Accreditation process. 
  • Thoroughly documenting al stages of project progress and the Accreditation process.
  • Estimates program needs and costs. Submits requisitions and proposals for materials / funding as necessary. 
  • Creates and maintains a "roadmap" to Accreditation Completion, inclusive of milestones, measurables, and accountabilities.


Accreditation Completion:
  • Monitors and enforces the "roadmap" to Accreditation completion. Provides regular and timely reports and updates on same to appropriate stakeholders.
  • Provides stakeholders with expertise and interpretation regarding Accreditation program standards and outcomes.
  • Manages and maintains documents and files pertaining to Accreditation.
  • Advises CEO of any risks, barriers, or deficiencies to achieving positive Accreditation results. 
  • Serves as point-of-contact to the Qmentum Accreditation team. Responds to any questions for Qmentum or refers to the appropriate stakeholder. Assists Qmentum surveyors on-site, including booking meeting space, etc. 



  • Reviews results of Accreditation with appropriate stakeholders.
  • Analyzes the resiliency and long-term sustainability of new practices, processes, and policies implemented as a result of Accreditation feedback. 
  • Makes recommendations for future budgetary expenditures relating to Accreditation, if applicable. 
  • Assists with the announcing of Accreditation results.
  • Ensures Accreditation-related files will be accessible and available to the appropriate parties going forward.  


Qualifications (Education, Experience, Abilities):





  • Post-secondary education in Health Care Administration or similar is preferred.
  • >> A post-secondary education in Nursing, Diagnostic Imaging, Laboratory, or other hospital clinical functions plus experience deemed relevant by the hospital may also be considered.
  • Formal training/courses in Project Coordination will be considered an asset. 





  • Minimum of five (5) years of Clinical hospital experience.
  • Previous experience with Qmentum Accreditation standards, Required Organizational Practices, survey tools, and other Accreditation Canada practices is a strong asset.
  • Demonstrated experience with and hollistical understanding of hospital clinical functions, as well as quality and continuous improvement activities within the healthcare context.
  • Experience supporting Leaders, Directors, Executives, and Board members.
  • Demonstrated history of success in Project fulfillment.
  • Demonstrated experience in Policy development and implementation.
  • Demonstrated history of success in change management.
  • Experience with information management systems, including data and records management.
  • Advanced computer skills using MS Outlook, MS Word, MS Excel, MS Powerpoint, Adobe Acrobat, databases, and survey tools (e.g.: SurveyMonkey).


Abilities and Service Skills:

  • Highly developed ability to organize and prioritize a constantly changing workload. Able to be assertive in managing time when necessary.
  • Able to work productively with a broad range of stakeholders and generate results on a project large in scope.
  • Possesses exceptional interpersonal skills to effectively build relationships and interact with others at all levels in the organization and outside the orgainziation.
  • Excellent business communication skills – both verbal and written – and the ability to communicate with all stakeholders. Able to communicate persuasively and influence others.
  • Capable of facilitating success in both group and individual settings.
  • Demonstrated proactive approaches to problem-solving. Capable of resolving matters within their scope independently.
  • Keen attention to detail.
  • Demonstrates strong initiative. Able to complete work with minimal direction/instruction.
  • Understanding of confidentiality and privacy requirements.
  • Current Police Check/Vulnerable Sector Screen and immunization status (including COVID-19 vaccination) required upon hire. 
Extra Information:

We are committed to providing persons with disabilities equal opportunities regarding all employment activities, including access to jobs and accommodations during employment as required, in accordance with the Ontario Human Rights Code (OHRC) and the Accessibility for Ontarians with Disabilities Act (AODA). Please advise the Human Resources department if you require accommodation.

Qualified individuals may submit a resume and covering letter in confidence via this website. Applications without cover letters will not be considered.


Your interest in this opportunity is appreciated. Only applicants selected for an interview will be contacted.

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