Occupations and Terms of Reference › Accreditation coordinator
Universal terms of reference · POS-028 · version 1.0 · status: draft · next review 2027-10-27
Accreditation coordinator
To coordinate accreditation work, so that evidence, action plans and survey preparation are organised and the organisation stays ready for review.
Each part of this page links to the related trainings, competencies and policies. The links are the same for every facility, so an organisation can see at a glance what a role requires and what it is trained in.
Job description
Job summary. You coordinate accreditation. You map evidence to each standard, track action plans, prepare for surveys, and make sure the organisation's accreditation file is complete and current.
Reports to: Quality manager.
Leads or supervises: No direct reports.
What you do on a typical day
- Maintain the standards evidence map.
- Track action plans and due dates.
- Prepare survey schedules and documents.
- Coordinate with the accreditation body.
- Report accreditation progress to the quality committee.
Working conditions and demands
- Deadlines are set by the accreditation body.
- Works across all departments.
- Needs strong organisation and attention to detail.
What good looks like
- Evidence is complete for every standard.
- Action plans are on track.
- Survey days run smoothly.
Place in the organogram
Reporting line, from the top: see the organogram on the Occupations page. The lines above and below this role are listed in section 3.
1. Golden rules
These rules apply in every setting.
- Every decision that affects patient safety is made on evidence and recorded.
- Quality means the patient's experience as well as the clinical result; both are measured.
- Problems are reported early and without blame, and learned from.
- Standards are followed the same way on every shift and at every site.
- Every staff member can raise a concern without fear of reprisal.
- Improvement work is planned, measured and kept going until it is embedded.
- Data is used to improve care, and is protected while it is used.
- Where a standard cannot be met, the gap is recorded and escalated the same day.
2. Identification
| Item | Detail |
|---|---|
| Position code | POS-028 |
| ISCO-08 | 2421 (skill level 4) |
| ESCO | to map |
| Department | Quality and safety |
| Facility types | Hospital, Ambulatory, Transport, Medevac, Fitness, Aesthetic |
3. Reporting line and working relationships
Reports to: POS-024. Supervises: .
| Works with | Nature of the relationship |
|---|---|
| Quality manager | Survey plan and actions. |
| Quality assurance officer | Evidence for standards. |
| Chief quality and safety officer | Accreditation decisions and reporting. |
4. Key accountabilities
| Domain | Accountability | Evidence of delivery | Checked | Linked competencies | Linked trainings | Linked policies | Standards |
|---|---|---|---|---|---|---|---|
| Evidence map | Keeps the evidence map current for each standard. | Map reviewed before each survey cycle | Quarterly | C-01 | T-07 | – | 1, 2 |
| Action plans | Tracks accreditation action plans to completion. | Plans current; overdue actions reported | Monthly | C-02 | T-08 | – | 2 |
| Survey preparation | Prepares survey documents and logistics. | Survey pack complete before visit | Quarterly | C-01 | T-07 | – | 1, 2 |
| External liaison | Coordinates communication with the accreditation body. | Correspondence logged and answered on time | Monthly | C-02 | T-08 | – | 2 |
5. Decision rights
| The post holder decides | Consults or escalates |
|---|---|
| Layout of evidence within the accreditation file | Requests from the accreditation body that cannot be met on time (quality manager and CQO) |
| Scheduling of internal reviews | Survey actions that need significant budget (quality manager and CFO) |
6. Qualifications and experience
| ID | Qualification | Mandatory | Validity |
|---|---|---|---|
| Q-01 | Degree in health management, nursing or a related field | Yes | Lifetime |
| Q-02 | Accreditation or quality surveyor training | No | Lifetime |
| ID | Experience | Minimum years | Mandatory |
|---|---|---|---|
| E-01 | Accreditation, quality or clinical administration experience | 3 | Yes |
7. Training requirements
Recommended common practice. Each facility adapts the list to its national law. Essential items apply in every setting; recommended items apply where resources allow.
| ID | Training | Tier | When | Validity | Linked policies | Linked competencies |
|---|---|---|---|---|---|---|
| T-01 | Facility induction | essential | at_entry | Once | POL-WHISTLE · POL-EQUAL · POL-DATA | – |
| T-02 | Safeguarding adults | essential | periodic | Every 3 year(s) | POL-SAFEG | – |
| T-03 | Safeguarding children | essential | periodic | Every 3 year(s) | POL-SAFEG | – |
| T-04 | Data protection and confidentiality | essential | annual | Every 1 year(s) | POL-DATA | – |
| T-05 | Incident reporting and open disclosure | essential | periodic | Every 2 year(s) | POL-INC | – |
| T-06 | Governance, accountability and assurance | recommended | periodic | Every 3 year(s) | – | – |
| T-07 | Emergency and major incident command | essential | annual | Every 1 year(s) | POL-INC | C-01 |
| T-08 | Speaking up, inclusion and equality leadership | essential | periodic | Every 2 year(s) | POL-WHISTLE · POL-EQUAL | C-02 |
8. Health, fitness and language
| ID | Requirement | Frequency | Tier | Minimum in low-resource settings |
|---|---|---|---|---|
| H-03 | Fitness-to-work assessment at entry and after serious illness or injury | Every 12 months | recommended | Fitness check at entry |
| Language | Level | Mandatory |
|---|---|---|
| Official language of the country of practice | professional | Yes |
| English | working | Yes |
9. Competencies by level
| ID | Competency | Foundation | Practitioner | Expert | Assessed by | Revalidate | Linked trainings |
|---|---|---|---|---|---|---|---|
| C-01 | Accreditation standards and evidence | Knows the standards | Maps evidence to standards | Designs the evidence system | Evidence audit | Every 12 months | T-07 |
| C-02 | Project and action coordination | Tracks own actions | Coordinates multiple actions | Designs coordination across departments | Coordination review | Every 12 months | T-08 |
10. Performance evaluation
- Probation: 6 months, with a sign-off review (recommended value).
- Appraisal: every 12 months against the competencies and indicators below.
| ID | Indicator | Target | Data source | Frequency |
|---|---|---|---|---|
| PI-01 | Standards with current evidence | 100% | evidence map | Quarterly |
| PI-02 | Action plans on track | 100% | action tracker | Monthly |
| PI-03 | Survey pack complete on time | 100% | survey tracker | Quarterly |
| PI-04 | Correspondence answered on time | 100% | correspondence log | Monthly |
11. Career ladder and promotion
| Level | Role | Minimum experience to move on | Qualifications | Competency minimums | Trainings required | Assessment |
|---|---|---|---|---|---|---|
| Executive | Accreditation coordinator | 3 years (recommended) | Q-01, Q-02 | C-01 practitioner, C-02 practitioner | T-07 | Executive appointment and performance review |
12. Policies the post holder follows
Each policy is a standard template that the facility adopts and adapts. Templates are maintained centrally, so every facility works from the same version.
POL-SAFEG · Safeguarding adults and children
Purpose: Protect patients from abuse, neglect and harm, and make sure every concern is recognised and acted on.
Scope: All staff, volunteers and contractors.
Key rules:
Scope: All staff, volunteers and contractors.
Key rules:
- Recognise signs of abuse and neglect and record them factually.
- Report every concern to the designated safeguarding lead the same shift.
- Do not investigate alone.
- Share information only as the safeguarding procedure allows.
POL-DATA · Data protection and confidentiality
Purpose: Keep patient and staff information private, secure and used only for care and legal purposes.
Scope: All staff who access records or systems.
Key rules:
Scope: All staff who access records or systems.
Key rules:
- Access only the records needed for your work.
- Keep records secure; do not leave screens or paper unattended.
- Do not share information without a lawful basis.
- Report any breach to the data protection officer within 24 hours.
Linked trainings: T-10 · Review every 12 months · Template 0.1 (draft)
POL-WHISTLE · Speaking up (whistleblowing)
Purpose: Let staff raise patient safety or conduct concerns without fear of reprisal.
Scope: All staff.
Key rules:
Scope: All staff.
Key rules:
- Raise a concern with your line manager or the named speaking-up officer.
- If that route fails, escalate to the board or the national regulator.
- Retaliation against anyone who speaks up is a disciplinary offence.
- Concerns are recorded, investigated and the outcome given to the person raising them.
Linked trainings: T-01 · Review every 12 months · Template 0.1 (draft)
POL-EQUAL · Equality, diversity and inclusion
Purpose: Give every patient and colleague fair access, respectful treatment and reasonable adjustments.
Scope: All staff and patients.
Key rules:
Scope: All staff and patients.
Key rules:
- Treat every person with dignity regardless of background.
- Make reasonable adjustments, including interpreters, for language and disability.
- Report discrimination through the speaking-up route.
- Monitor access and outcomes by group.
Linked trainings: T-01 · Review every 24 months · Template 0.1 (draft)
POL-INC · Incident reporting and open disclosure
Purpose: Report and learn from incidents and near misses, and tell patients honestly when things go wrong.
Scope: All staff.
Key rules:
Scope: All staff.
Key rules:
- Report every incident and near miss the same shift.
- Give the patient and family an honest account and an apology where appropriate (open disclosure).
- Take immediate action to protect others.
- Learn: contribute to the review and follow the agreed actions.
13. Standards that name this role
14. Record history
| Date | Change | Approved by |
|---|---|---|
| 2026-10-27 | Draft record, batch 1 of the position build | Awaiting approval |