Job Description
The Accreditation Lead, Integrated Care Solutions (ICS), provides end-to-end leadership for accreditation preparedness, sustainment and continuous readiness across Transitional Care Units (TCU), At-Home/Community and the Neurological Rehabilitation Institute of Ontario (NRIO). The role translates Accreditation Canada and Health Standards Organization requirements into coordinated, evidence-based operational practices; leads self-assessments, gap analysis and corrective action planning; and enables leaders and frontline teams to demonstrate safe, high-quality, person- and family-centred care.
The Lead is the primary accreditation subject-matter resource for ICS and works across the Clinical Quality, Health Information & Privacy (CQ-HIP) department, ICS operations, clinical leadership, hospital and community partners, and Accreditation Canada. The role maintains the integrated accreditation roadmap, governance structure, evidence repository, risk register and executive reporting required to sustain readiness throughout the full accreditation cycle.
KEY ACCOUNTABILITIES
1. Accreditation Strategy, Program Governance and Cycle Management
• Lead the multi-year ICS accreditation preparedness and sustainment program, including the integrated roadmap, master work plan, milestones, dependencies, resource needs and decision log.
• Maintain alignment across TCU, At-Home/Community and NRIO while recognizing program-specific standards, care settings, partner requirements and legitimate scope differences.
• Chair or coordinate the ICS Accreditation Committee and related working groups; prepare agendas, decision materials, minutes, action logs and follow-up communications.
• Provide regular status briefings to CQ-HIP and ICS leadership, clearly identifying decisions required, emerging risks, overdue actions and mitigation strategies.
• Serve as the principal liaison with Accreditation Canada for program scope, assessment manuals, survey-cycle requirements, submissions, evidence follow-up and clarification of standards.
2. Standards Interpretation, Self-Assessment and Readiness Validation
• Maintain current working knowledge of Accreditation Canada, Health Standards Organization standards, Required Safety Practices (RSPs), high-priority criteria and applicable regulatory or funder requirements.
• Interpret requirements for ICS programs and convert them into practical assessment tools, evidence expectations, implementation guidance and readiness criteria.
• Design and facilitate structured self-assessments, leadership reviews, mock tracers, audits and validation sessions with multidisciplinary and frontline participation.
• Calibrate compliance ratings using current-state practice and objective evidence; challenge unsupported "met" or "not applicable" ratings and document rationale for final determinations.
• Coordinate partner-facing accreditation readiness for TCUs, including alignment with hospital-partner expectations without creating avoidable duplication of survey effort.
3. Gap, Risk, CAPA and Action-Plan Management
• Identify compliance gaps, operational risks and evidence weaknesses; assess priority, impact and level of effort; and escalate material risks promptly.
• Lead development of corrective and preventive action plans (CAPAs), Plans of Correction and program-level gap action plans with clear owners, milestones, evidence requirements and closure criteria.
• Maintain centralized trackers, dashboards and risk registers; monitor progress, validate closure evidence and report sustained compliance rather than activity completion alone.
• Connect accreditation findings with internal audits, quality improvement plans, incident trends, patient/client experience insights and partner feedback to drive system-level improvement.
• Coordinate timely responses to Accreditation Canada follow-up requirements and support preparation of complete, accurate evidence packages.
4. Evidence, Documentation and Information Management
• Govern the ICS accreditation evidence repository in SharePoint, including folder architecture, document naming, version control, evidence indexing, access and retention expectations.
• Define evidence ownership for program and functional-area leads and provide oversight so collection and maintenance are distributed and sustainable.
• Review policies, procedures, SOPs, education records, audit results, committee records and reports for currency, traceability and alignment with standards.
• Develop and maintain scorecards, dashboards, briefing notes, executive reports, presentations, crosswalks and survey-readiness documentation.
• Use data and qualitative findings to identify trends, compare performance across services and recommend targeted improvement priorities.
5. Operational Integration, Education and Change Leadership
• Partner with operational, clinical and corporate leaders to embed accreditation requirements into everyday workflows, governance, onboarding, education, quality committees and performance monitoring.
• Develop and deliver practical education, coaching, tools and communications for leaders, staff, accreditation champions, patients/clients and family partners.
• Build awareness of the "why" behind requirements and support teams to articulate how standards are demonstrated in practice.
• Promote person- and family-centred care, health equity, workforce safety and well-being, client safety, client flow and safe use of medical devices and equipment within readiness activities.
• Lead change using collaborative, respectful and accountable approaches that recognize operational capacity while maintaining required standards.
6. Survey Planning and Stakeholder Coordination
• Plan and coordinate survey logistics, schedules, site and program profiles, document submissions, interview and tracer preparation, surveyor support and leadership readiness.
• Build and maintain effective working relationships with ICS leaders, CQ-HIP subject-matter experts, hospital and community partners, funders, Accreditation Canada and patient/family advisors.
• Ensure frontline staff and patient/family perspectives are incorporated into self-assessments, quality-improvement work and readiness validation.
• Coordinate post-survey debriefs, lessons learned, evidence follow-up and transition from survey preparation to sustained operational ownership.
7. Quality, Safety and Corporate Responsibilities
• Participate in quality improvement, patient safety, emergency preparedness and business continuity activities that intersect with accreditation requirements.
• Protect the confidentiality and privacy of patient/client, employee and corporate information and use information only for authorized purposes.
• Participate in proactive health and safety activities and promptly report identified risks or concerns.
• Comply with Bayshore, funder and partner policies and complete other related duties consistent with the scope and level of the role.
Qualifications
Education
• Bachelor's degree in health care, health administration, quality, social sciences, business or a related discipline. A relevant master's degree is an asset.
• Formal education or certification in quality improvement, patient safety, project management, change management or accreditation is an asset.
Experience
• Progressive experience in health care quality, accreditation, patient safety, program management or a comparable role.
• Recent hands-on experience leading or supporting an Accreditation Canada or comparable health-care accreditation program is required.
• Demonstrated experience facilitating multidisciplinary groups, conducting assessments or audits, developing action plans and preparing leadership-level reports.
• Experience working across multiple health-care settings, programs or partner organizations is strongly preferred.
Knowledge
• Strong working knowledge of accreditation standards, evidence-based compliance validation, quality improvement and patient safety principles.
• Understanding of Canadian health-care delivery, including home and community care, transitional or inpatient services, rehabilitation and partner-funded care models.
• Knowledge of person- and family-centred care, health equity, emergency preparedness, risk management, policy governance and continuous quality improvement.
Technical skills
• Advanced proficiency with Microsoft 365, including Word, Excel, PowerPoint, Teams and SharePoint.
• Ability to effectively use AI tools to streamline work tasks.
• Ability to build and maintain complex trackers, work plans, scorecards, dashboards and evidence repositories.
• Strong written communication, policy and procedure writing, data interpretation, presentation and executive briefing skills.
WORKING CONDITIONS
• Home-based role with regular virtual collaboration and periodic in-person work at Bayshore offices, ICS program locations, partner sites and accreditation-related events.
• Travel within Ontario and occasional travel outside the province may be required.
• Workload and scheduling may intensify during assessments, partner surveys, mock tracers, evidence deadlines and formal Accreditation Canada survey periods.
• Must be able to manage confidential information, competing priorities and time-sensitive deliverables with a high degree of independence.
