Job Details


Company name
Moses Cone Health System

Greensboro, NC

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Position Title:

Accreditation & Patient Safety Coordinator


50791-SW-Accreditation Services

Job Interest Category:


Job Interest (specific):



Other Campus/Loc



Work Schedule:

8 hour days

Specific Work Schedule Detail:

8 hour days

Hours per week:



Our Purpose

Together, we create unsurpassed health care experiences.

Our Intent

We are the leader in delivering integrated, innovative health care.

Our Values

At Cone Health, we value and are accountable for:

· Caring for Our Patients

We provide exceptional quality, compassionate care and service in a safe, respectful environment.

· Caring for Each Other

We appreciate each other through honest communication and respect. We inspire ongoing learning, pride, passion and fun.

· Caring for Our Communities

We engage our communities with integrity and transparency. We embrace our responsibility to promote health and well-being.

Education / Licensure / Certification:



Graduate of RN Educational Program with BSN or BSN in progress to be completed within 4 years.

Bachelor's degree in Medical Technology or other health related field is acceptable.


Master's Degree in Nursing or Business Administration



Registered Nurse with current NC license


Quality, Accreditation or Patient Safety Certification




At least 3 years' experience in acute healthcare setting. Experience in data analysis.


Previous experience with regulatory compliance


Must have ability to clearly communicate verbally, in person, and in writing with patients, families, regulatory agencies and the health care team.

Ability to analyze data.

Ability to analyze work processes for patient safety and performance improvements.

Ability to work independently.

Ability to influence others.


Sedentary Work:

Exerting up to 10 pounds of force occasionally (up to 1/3 of the time) and/or; a negligible amount of force frequently (1/3 to 2/3 of the time) to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Job are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.


Hear and differentiate low volume sounds in order to make judgments regarding actions needed

Hear alarm bells, verbal conversations, telephone voices and normal volume sounds

Close vision (clear vision at 20 inches or less)

Distance vision (clear vision at 20 feet or more)

Depth perception (three-dimensional vision, ability to judge distances and spatial relationships)

Color vision (ability to identify and distinguish colors)


* Annual flu shot

* Annual TB test (if applicable to your job location)

* Annual HLCs (Healthstream, formerly CBL)-Safety at Work and Corporate Compliance

* Maintain licensure/certification/registry/listing (if applicable to your job)

Job Description:


Responsible for collaborating with leadership to prepare the organization with ongoing programs to promote continuous accreditation readiness, clinical compliance, and patient safety improvement for assigned facility(s).


Assist leadership in defining key performance indicators and developing measurement tools to evaluate accreditation and patient safety process improvements; coordinates patient safety culture assessment efforts 10 %

Assists with coordination of accreditation and patient safety readiness meetings, discusses barriers to continual readiness, changes in regulations, develops action plans, measures sustainability and reassesses approach to maximize success 10 %

Collaborates with leadership to complete required regulatory reports to include investigating and developing an improvement response plan for regulatory complaints and sentinel events. 10 %

Facilitates tracers, medical record reviews, and environmental assessments, compiles and distributes compliance reports to departments, as well as facility and system oversight teams. 15 %

Guides and coaches leaders and frontline staff in the development of accreditation and patient safety improvement initiatives; provides direction to department and facility leadership in the planning of a systematic, organization-wide approach to continuous accreditation readiness and patient safety improvement opportunities. 15 %

Maintains open communication and a close working relationship with facility leadership to optimize patient safety culture and to support a constant state of readiness for accreditation reviews 15 %

Serves as a subject matter expert, addressing all aspects of pre-survey, survey and post-survey activity including the planning and execution of The Joint Commission annual intracycle reviews. 10 %

Utilizes facilitation skills with proactive risk assessments, and other patient safety process reviews to include assistance with root cause analysis for breakdowns. 15 %


Occurs under one-third of the time:

Exposure to bloodborne pathogens

Hazardous waste and/or toxic/caustic chemicals

Fumes or airborne particles

Additional information on working conditions:

Sufficient mobility to move within and between Cone Health sites. Ability to visualize a computer monitor and use a computer keyboard. Ability to use automated communication devices.



I will create and engage in conversations of possibility.

o I will be open to innovation and creativity.

o I will listen to understand.

o I will bring ideas for solutions and be open to alternative ideas.

o I will be open to constructive feedback.

o I will not engage or listen to negativity or gossip.

o I will be positive when speaking about Cone Health, my department, and my coworkers.

o I will be approachable.

o I will focus on behaviors, not the person, during conflict.


I will honor my word.

o I will do what I say when I say I will. o I will “clean it up” when I can’t keep my word.

o I will honor my work agreement.

o I will be “on the court” instead of “in the stands.”

o I will follow up in a timely manner on commitments and requests.

o I will apologize when someone experiences less than excellent service. o I will take responsibility for my actions, decisions and performance.

o I will protect patient safety (best practices: ex – hand hygiene).


I will assume the best of intentions and embrace differences.

o I will collaborate and seek other people’s input.

o I will demonstrate courtesy, compassion, and respect with my tone of voice and body language.

o I will speak positively about Cone Health – managing up coworkers, physicians, departments, patients and visitors.

o I will ask the person directly involved when I don’t know.

o I will include diverse skills, abilities, strengths, and backgrounds to create better outcomes.

o I will care for myself while also respecting others.


I will own it, solve it, and celebrate it!

o I will offer solutions when problems are identified.

o I will share my input for decisions by participating in forums such as shared governance, town halls, employee engagement survey, brown bag discussions, employee councils, staff meetings, or directly with my manager.

o I will take charge and do the right thing at the right time.

o I will make decisions keeping a balance of service, quality, and cost in mind.

o I will demonstrate Cone Health values.

o I will seek opportunities to celebrate and have fun.

o I will recognize good work.

I have seen and reviewed the job description in its completed form and understand that I will be required to perform all functions listed if hired for this position. I recognize that, if hired, it is my responsibility to notify my manager as soon as possible if I am unable to perform any of the functions of my position for any reason. This job description is not intended to be an exhaustive list of all duties, responsibilities, or qualifications associated with the job.

Exceptional People Providing Exceptional Care!

Cone Health is a state of the art network of facilities providing patients access to the latest developments in medical care from their first moments of life through later years. Our network offers the most breakthrough treatments and technology available in healthcare today. As a teaching hospital, we offer employees the opportunity to become leaders in the industry and continued growth from their first day on.

Extraordinary patient care is about being high-touch as well as high-tech. Community service and superior patient care are the cornerstones of our organization, a philosophy that is demonstrated by each and every one of our valued team members. We are proud to be the largest private, not-for-profit employer of choice in the Piedmont, NC area community!

Cone Health is an equal opportunity employer. If you require assistance with our online job submission process, please contact our Talent Acquisition team at 866-266-3767 to request an accommodation. Additionally, Cone Health invites interested deaf and hard of hearing applicants to use Video Relay Service (VRS).


Company info

Moses Cone Health System
Website :

Company Profile
Moses Cone Health System is a multi-hospital system with a range of outpatient services designed to provide care for Piedmont residents throughout all stages of their lives. Residents of our primary service area of Guilford, Randolph, Rockingham and Alamance counties and the city of Kernersville depend on us for convenient, affordable and compassionate care - care delivered regardless of a patient s ability to pay.

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