Coordinator, Accreditation, Patient Safety Ambulatory

At NorthBay Health, the Ambulatory Accreditation and Patient Safety Coordinator, in collaboration with the Accreditation, Regulatory and Licensure Manager assists in providing leadership and direction to the organization in to ensure smooth management of Accreditation, Regulatory and Licensure activities. Will also coordinate, along with the Patient Safety Program Manager, patient safety programs system wide.  The Accreditation and Patient Safety Coordinator is responsible for coordinating ambulatory and outpatient ongoing processes for continuous patient readiness including the maintenance of a system wide calendar of all accreditation, licensure and other regulatory survey activities; monitoring of all required action plans for completion in required time frames and maintains a database of compliance audit responses of CDPH, CMS, and Joint Commission action plans; and coordination of the JCR AMP Intracycle Accreditation Assessment which is used to continually monitor organizational compliance with The Joint Commission Standards and CMS requirements. The coordinator assists with maintaining and updating the ambulatory and outpatient Accreditation, Licensure, and Regulatory Share Space page with articles, resources, hot topics, tips for survey prep, and audit tools to help engage staff in being prepared for surveys. Participates in the actual survey process by functioning as a key role in the Command Center.  Assists with California Department of Public Health and Joint Commission Licensing applications, changes, and assists with CDPH complaint paperwork. The ambulatory and outpatient Accreditation and Patient Safety Coordinator is able to work independently utilizing a high level of initiative, judgment, organization, and critical thinking skills. This position assists in the development, implementation and sustainment of the patient safety program that addresses the prevention of errors to patients, the evaluation of risk events to determine opportunities to improve care through risk reduction strategies and the distribution of patient safety data to the organization.  This position is responsible for assisting the Managers of Accreditation, Regulatory and Licensure and the Patient Safety Program Manager in establishing and maintaining a culture of safety at NorthBay Health. This position supports NorthBay’s journey in being recognized as a High Reliability Organization and in the pursuit of zero harm for our patients through evidenced based practice and patient safety expertise. He/she provides feedback and suggests recommendations for organizational changes to leaders to promote safer patient care delivery for both inpatient and ambulatory care patients. 

1. Education:  Baccalaureate Degree health sciences or related field.

2. Experience: Minimum of four years of administrative support in healthcare experience. Minimum of two years relevant experience in the areas of process improvement, change management, or equivalent and a solid working knowledge of improving patient safety. Demonstrated initiative, follow through and ability to work independently. Demonstrated effective project management skills. Experience with accreditation, licensure and regulatory paperwork, action plans and surveys. Microsoft Office experience

3. Skills: Excellent written and verbal communication and presentation skills. Must be able to deal with job-related stress, multiple projects and deadlines. Advanced computer skills (spreadsheets, graphs, tables and reports).

4. Interpersonal Skills: Demonstrates the True North values. The True North values are a set of value-based behaviors that are to be consistently demonstrated and role modeled by all employees that work at NorthBay Health. The True North values principles consist of Nurture/Care, Own It, Respect Relationships, Build Trust and Hardwire Excellence.  

5. Hours of Work: Full-time hours based on business needs. 

6. Compensation: $45 to $54.79 an hour based on years of experience doing the duties of the role.

At NorthBay Health, we are guided by our values: Nurturing Care; Own It; Respect; Build Trust; and Hardwire Excellence. These principles lead us to our TRUE NORTH and inspire us to provide exceptional care. 

These values serve as the foundation of everything we do, guiding us to deliver individualized care with integrity and accountability. We are committed to fostering a culture of collaboration, where every team member is valued and empowered to contribute their best to the health and well-being of those we serve. 

This is an exciting time to join NorthBay Health.

As an independent, nonprofit health system north of the San Francisco Bay Area, in the Napa/Solano Region, we are expanding our footprint across Solano, Yolo, and Napa counties to meet the evolving needs of our communities. With two acute-care hospitals—including a Level II Trauma Center and a modern maternity unit with a Level III Neonatal Intensive Care Unit (NICU)—along with a comprehensive cancer center, multiple urgent care facilities, and a growing network of primary and specialty clinics, we are investing in the future of care across the region.

NorthBay Health we are home to advanced clinical programs and nationally recognized cardiovascular, neuroscience, and orthopedic services, as well as comprehensive surgical and outpatient specialties. Our commitment to excellence is reflected in our Magnet with Distinction designation for nursing (one of only 12 organizations nationwide) and recognition from U.S. News & World Report as “High Performing” in multiple clinical areas, including maternity care, heart failure, and stroke. NorthBay Medical Center has earned the High Performing designation in maternity care for four consecutive years.

As the only locally governed health system in the region, we remain deeply rooted in our communities while growing into a trusted regional healthcare leader. If you are seeking meaningful work, collaborative teams, and the opportunity to help shape the future of healthcare in Northern California, you will find it at NorthBay Health.

Join us with our commitment to excellence, to achieve our vision to be the trusted healthcare partner of choice for the communities we serve.

To learn more about NorthBay Health's benefits, diversity statement and community please visit