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Galileo Search Published: April 26, 2023


Program Director Regulatory and Accreditation | Enterprise Level | Healthcare System | Texas

Competitive Compensation | Superb Benefits Program | Relocation Assistance

Our client is a High-Reliability Organization and not-for-profit healthcare system known for its diverse workforce, employee-centric approach, and delivery of world-class patient care.

The selected candidate for this high-profile role will direct organization-wide processes for evaluating, monitoring, and improving compliance with internal and external regulatory requirements. This includes standardizing the organization’s processes to prepare for, participate in and follow up on regulatory, accreditation, and certification surveys and activities. The Program Director will serve as a consultant to executive officers and directors to review and consult on the regulatory effect of new initiatives, evaluate organizational processes, and partner with individuals at all levels of the organization to implement change.

This role is anchored in a thriving metropolitan area with beautiful green spaces, parks, recreation, aquatic centers, art venues, state-of-the-art transportation, flourishing businesses, nearby airports, world-class shopping, and hundreds of restaurants with diverse cuisines. This location is ranked highly among the Best Places to Live in America.




• Reports to the Corporate Vice President, Quality & Safety
• Provides leadership and direction for regulatory and accreditation to the organization
• Standardizes the organization’s processes to prepare for, participate in and follow up on regulatory, accreditation, and certification surveys and activities
• Guides the corrective action plans developed by leaders from areas with deficiencies
• Develops the frameworks and evaluation methods for continuous readiness programs for all aspects of the organization
• Provides coaching to members of the leadership team on regulatory preparedness
• Works closely with senior leaders to develop improvements in the organization
• Ensures that key executive leaders are informed of survey progress and Regulatory challenges across the organization
• Evaluates the enterprise Regulatory and Accreditation process and ensure that the ongoing monitoring addresses the issues cited without causing new areas of noncompliance downstream
• Communicates the survey results and ramifications of the findings to individuals at all levels of the organization
• Assists in policy implementation for processes and programs, facilitating regulatory and accreditation compliance with federal and state laws and regulations
• Cultivates a safe healthcare environment by promoting best practices, nurturing a Just Culture, and improving processes that detect, mitigate, and prevent harm
• Utilizes performance and process improvement (PPI), project management, and change management methods to support operational and clinical quality initiatives, improve performance, and achieve organizational goals
• Leverages the organization's analytic environment to help guide data-driven decision-making and inform quality improvement initiatives
• Advances the organization's commitment to healthcare quality through collaboration, learning opportunities, and communication
• Leads the integration of quality into the fabric of the organization through a coordinated infrastructure to achieve organizational objectives
• Builds bridges, is transparent, authentic, and inspires others
• Remains persistent, eliminates objectives, makes an impact, drives excellence
• Engages in the healthcare quality profession with a commitment to practicing ethically, enhancing one's competence, and advancing the field


• Bachelor's Degree in Nursing or other clinical discipline preferred or BA/BS with applicable certifications; Master’s Degree preferred
• CPHQ (Certified Professional in Healthcare Quality) or obtained within 1 year of hire
• 5+ years of progressive experience in a large complex healthcare environment
• 3+ years of acute care quality management/leadership experience
• Knowledgeable of agencies such as Joint Commission and CMS
• Proficient in computer skills using EXCEL, PowerPoint, MSOffice, and Flowchart tools
• Familiar with High-Reliability Principles and PDSA methodology
• Knowledgeable on payment models for quality metric performance
• Ability to establish and maintain effective working relationships with all levels of hospital staff

About Galileo Search:

Galileo Search, LLC partners with hospitals and healthcare organizations across the United States to identify, recruit and retain the most accomplished professionals and executives in the industry. Our clients include community and critical access hospitals, health systems, academic medical centers, and Fortune 500 corporations. To learn more about Galileo Search, LLC, visit our website at

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