Continuous Quality Improvement and Accreditation Coordinator

Ponce Health Sciences University - St. Louis; Piura; On-site; PEN 240,000 - 378,000; Full time

Job summary

Ponce Health Sciences University - St. Louis is seeking a CQI and Accreditation Coordinator to lead the School of Medicine’s continuous quality improvement activities and contribute to programmatic and institutional accreditation.

The role develops evidence-based indicators, prepares accreditation reports, presents findings to committees, and tracks corrective actions through implementation and reassessment, ensuring alignment with ACCM, MSCHE, and other accreditors.

Qualifications

• Five years of progressive experience in accreditation, institutional effectiveness, educational assessment, quality assurance, or CQI in higher education.
• Direct ACCM and MSCHE experience is required or strongly preferred.
• Experience developing performance indicators, validating data, and creating dashboards for institutional decisions.
• Ability to present findings to committees and track action plans across multiple offices.
• Experience coordinating with accreditation liaison offices and auditing evidence for compliance.

Responsibilities

• Coordinate CQI and accreditation activities and maintain a standards mapping matrix.
• Develop, monitor, and review annual CQI and accreditation work plans.
• Identify gaps, propose evidence-based actions, and assign responsible owners with timelines.
• Prepare accreditation narratives, self-studies, monitoring reports, and responses to findings.
• Coordinate visits, readiness activities, and follow-up documentation with relevant offices.

Skills

Data analysis

Quality improvement

Accreditation knowledge

Communication skills

Project management

Spanish language proficiency

Education

Master’s degree in Higher Education Administration, Educational Assessment or Evaluation, Medical/Health Professions Education, Public Health, Healthcare Administration, Quality Management, Actuarial Science or related fields

Bachelor’s degree in related field considered with relevant experience

Job description

THIS POSITION MAY BE LOCATED IN THE BRITISH VIRGIN ISLANDS OR OUTSIDE THE BVI WITH REGULAR TRAVEL.

Summary/Objective

The Continuous Quality Improvement (CQI) and Accreditation Coordinator coordinates the School of Medicine’s continuous quality improvement activities and its contributions to programmatic and institutional accreditation. The position maintains an organized, evidence-based process for evaluating compliance, identifying gaps, developing improvement proposals, and verifying the effectiveness of corrective actions.

The Coordinator works closely with academic and administrative leadership, faculty, institutional offices, and relevant committees to support compliance with applicable requirements of the Accreditation Commission on Colleges of Medicine (ACCM), the Middle States Commission on Higher Education (MSCHE), and other accrediting bodies within the assigned scope. The role develops and validates quality indicators, prepares accreditation reports, presents findings and recommendations to appropriate committees, and tracks approved actions through implementation and reassessment.

The position supports institutional accountability and informed decision‑making. Academic and administrative leaders retain responsibility for decisions, implementation within their areas, and formal approval of accreditation submissions.

Essential Functions

• Develop, coordinate, and maintain an annual CQI and accreditation work plan identifying applicable standards, evaluation activities, responsible parties, deliverables, review schedules, and reporting deadlines.
• Maintain a standards compliance matrix linking accreditation requirements to institutional policies, supporting evidence, responsible offices, performance indicators, identified gaps, and improvement actions.
• Monitor changes to applicable accreditation standards, policies, procedures, and reporting requirements; assess their implications and communicate necessary actions to leadership and responsible units.
• Coordinate programmatic accreditation activities with academic leadership and institutional accreditation activities with the designated institutional accreditation liaison and relevant central offices.
• Conduct periodic compliance reviews, gap analyses, and internal readiness assessments across assigned academic and administrative areas, documenting findings and prioritizing risks.
• Develop evidence-based improvement proposals that specify the problem, supporting data, probable causes, recommended actions, resource implications, accountable owners, completion dates, and measures of success.
• Present compliance findings, quality indicators, and improvement proposals to the appropriate curriculum, assessment, student affairs, faculty, administrative, accreditation, and institutional effectiveness committees, as applicable.
• Maintain records of committee recommendations and decisions, assigned responsibilities, implementation deadlines, and follow-up requirements. Escalate unresolved risks and overdue actions through established reporting channels.
• Coordinate implementation monitoring with responsible departments and verify the effectiveness and sustainability of completed actions before recommending closure.
• Design, document, and periodically review quality and continuous improvement indicators in collaboration with institutional research, assessment personnel, and relevant operational units.
• Establish indicator definitions, calculation methods, data sources, baselines, targets, review frequencies, responsible owners, and thresholds requiring investigation or corrective action.
• Verify the accuracy, completeness, consistency, and traceability of reported data; reconcile discrepancies with data owners and document material limitations.
• Analyze trends in student achievement, progression, retention, completion, licensing examination performance where applicable, educational experiences, student support, faculty development, and other indicators relevant to accreditation and institutional priorities.
• Evaluate the consistency of educational experiences and outcomes across campuses, instructional settings, and clinical training sites, as applicable, in collaboration with the responsible academic leaders.
• Develop and maintain dashboards, compliance summaries, and periodic CQI reports that communicate results, risks, actions taken, and evidence of improvement.
• Draft, compile, edit, and present accreditation self‑studies, annual reports, monitoring reports, progress reports, responses to findings, and other required submissions within the assigned scope.
• Verify that accreditation narratives are supported by current evidence, accurately reflect institutional practices, and are consistent across reports. Coordinate review, approval, and timely submission through authorized institutional channels.
• Maintain a secure, organized accreditation evidence repository with standards mapping, document ownership, version control, review dates, and appropriate access permissions.
• Coordinate accreditation visits and related readiness activities, including evidence requests, schedules, briefing materials, participant preparation, and follow‑up documentation.
• Track accreditor findings, recommendations, and required actions; coordinate response plans and retain evidence demonstrating resolution and subsequent monitoring.
• Work with the designated accreditation liaison to identify proposed changes that may require accreditor notification or approval and coordinate the necessary documentation and timelines.
• Support the alignment of assessment findings and improvement priorities with strategic planning, operational planning, and resource allocation.
• Provide training and guidance to faculty, staff, and committee members on accreditation requirements, evidence documentation, indicator interpretation, and continuous improvement methods.
• Review the effectiveness of the CQI process itself and recommend improvements to reporting, governance, data collection, and follow‑through.
• Perform other related duties assigned by the supervisor in support of educational quality, accreditation, and institutional effectiveness.

Supervisor Responsibility

This position does not initially have direct supervisory responsibilities. The Coordinator provides functional coordination for accreditation working groups and CQI activities, monitors assigned deliverables, and follows up with designated contributors. Personnel supervision and departmental decision‑making remain with the appropriate supervisors and leaders.

Work Environment

This position operates primarily in an academic and administrative office environment and involves regular collaboration with faculty, staff, institutional leaders, and committee members. Work includes data analysis, document preparation, committee presentations, accreditation preparation activities, and coordination across campuses or clinical sites, as applicable.

The role routinely uses computers, institutional information systems, data reporting tools, document management platforms, videoconferencing applications, and standard office equipment.

Physical Demands

The employee must be able to perform the essential functions of the position, with reasonable accommodation as applicable. Duties involve sustained computer work, reviewing detailed documents and data, communicating in meetings and presentations, and moving between campus offices and meeting spaces. Accreditation activities may require attendance at other institutional locations or clinical training sites.

Position Type / Expected Hours of Work

This is a full‑time, in‑person position. Regular work hours are generally Monday through Friday. Occasional evening or weekend work may be required during accreditation visits, reporting periods, or other time‑sensitive institutional activities.

Travel

Occasional travel may be required to institutional campuses, clinical training sites, accreditation meetings, and professional development activities.

Required Education And Experience

Education: An earned master’s degree from an appropriately accredited institution in Higher Education Administration, Educational Assessment or Evaluation, Medical or Health Professions Education, Public Health, Healthcare Administration, Quality Management, Actuarial Science, or a closely related field, including Data Science, Statistics, and Mathematics. Candidates holding a bachelor’s degree in these fields may be considered based on the depth, relevance, and demonstrated outcomes of their professional experience, provided they meet all required professional experience criteria.

Priority of Professional Experience: Demonstrated relevant professional experience is the primary selection criterion. Candidates from different academic backgrounds will be considered when they meet the required experience in accreditation, continuous quality improvement, data analysis, and institutional effectiveness, including direct, substantive experience with both ACCM and MSCHE processes. An advanced degree does not substitute for the required professional experience.

Relevant professional experience: A minimum of five years of progressively responsible experience in accreditation, institutional effectiveness, educational assessment, quality assurance, or continuous quality improvement in higher education.

Medical or health professions education experience: Within the five years above, at least three years of experience supporting a medical school or another health professions education program.

ACCM experience: Direct, substantive experience supporting an ACCM accreditation review, including preparation or coordination of standards‑based narratives and evidence, readiness assessment or visit preparation, and follow‑up on findings or improvement actions. General familiarity with ACCM standards alone does not satisfy this requirement.

MSCHE experience: Direct, substantive experience supporting at least one MSCHE self‑study, monitoring report, or other formal accreditation review process, with identifiable responsibility for narrative development, evidence coordination, compliance analysis, or responses to findings. Conference attendance or general familiarity alone does not satisfy this requirement.

Quality improvement experience: Demonstrated responsibility for at least one documented improvement initiative from problem identification and baseline measurement through implementation, reassessment, and reporting of results.

Measurement and analysis experience: Demonstrated experience developing performance indicators, validating data, analyzing trends, and preparing dashboards or reports used for institutional decisions.

Committee and reporting experience: Demonstrated experience presenting findings and recommendations to academic or administrative committees and tracking resulting action plans.

The experience requirements above may overlap and do not represent cumulative additional years. Candidates must be able to explain their specific responsibilities and contributions in both ACCM and MSCHE processes.

Additional Requirements

Working knowledge of applicable ACCM standards and MSCHE standards, requirements of affiliation, accreditation policies, and reporting procedures.

Ability to distinguish programmatic from institutional accreditation responsibilities and coordinate effectively across their respective governance structures.

Strong command of written and spoken English, including the ability to produce clear, accurate accreditation narratives and present findings to senior leadership.

Proficiency in Microsoft Word, Excel, and PowerPoint, including spreadsheet formulas, pivot tables, data validation, and charts.

Ability to interpret quantitative and qualitative evidence, identify data limitations, and translate findings into practical recommendations.

Ability to manage concurrent projects, obtain contributions from multiple offices, and meet external deadlines.

Ability to handle confidential student, personnel, institutional, and accreditation information in accordance with applicable policies and requirements.

Ability to apply structured improvement methods, such as Plan-Do-Study-Act, process mapping, and root cause analysis.

Preferred

Doctoral degree in a field relevant to educational quality, assessment, institutional effectiveness, or health professions education.

Applied knowledge of ISO 9001, Quality Management Systems, and ISO 21001, Educational Organizations Management Systems, including process documentation, internal evaluation, corrective action, and continual improvement.

Formal training or a recognized credential in quality management, internal auditing, Lean Six Sigma, or project management.

Experience with accreditation or quality assurance in Caribbean, international, or multicampus medical education settings.

Experience using business intelligence or statistical analysis tools, such as Power BI, Tableau, SPSS, or R.

Experience serving as an accreditation working group lead, internal reviewer, or external peer evaluator.

Spanish language proficiency.