Accreditation Lead, Integrated Care Solutions

Bayshore Health Care is one of the Canada’s leading providers of home and community health care services and is a privately owned company. Bayshore Health Care is proud to showcase its achievement as a Platinum member of Canada’s Best Managed Companies Program every year since 2006. Bayshore Healthcare is also recognized as Canada’s Best Employers in Forbes 2023 list.

The Accreditation Lead, Integrated Care Solutions (ICS), provides end-to-end leadership for accreditation preparedness, sustainment and continuous readiness across Transitional Care Units (TCU), At-Home/Community and the Neurological Rehabilitation Institute of Ontario (NRIO).

The role translates Accreditation Canada and Health Standards Organization requirements into coordinated, evidence-based operational practices; leads self‑assessments, gap analysis and corrective action planning; and enables leaders and frontline teams to demonstrate safe, high-quality, person‑ and family‑centred care.

The Lead is the primary accreditation subject‑matter resource for IC be and works across the Clinical Quality, Health Information & Privacy (CQ‑HIP) department, IC be operations, clinical leadership, hospital and community partners, and Accreditation Canada.

The role maintains the integrated accreditation roadmap, governance structure, evidence repository, risk register and executive reporting required to sustain readiness throughout the full accreditation cycle.

• Lead the multi-year IC be accreditation preparedness and sustainment program, including the integrated roadmap, master work plan, milestones, dependencies, resource needs and decision log.
• Maintain alignment across TCU, At-Home/Community and NRIO while recognizing program‑specific standards, care settings, partner requirements and legitimate scope differences.
• Chair or coordinate the IC be Accreditation Committee and related working groups; prepare agendas, decision materials, minutes, action logs and follow‑up communications.
• Provide regular status briefings to CQ‑HIP and IC be leadership, clearly identifying decisions required, emerging risks, overdue actions and mitigation strategies.
• Serve as the principal liaison with Accreditation Canada for program scope, assessment manuals, survey‑cycle requirements, submissions, evidence follow‑up and clarification of standards.

• Maintain current working knowledge of Accreditation Canada, Health Standards Organization standards, Required Safety Practices (RSPs), high‑priority criteria and applicable regulatory or funder requirements.
• Interpret requirements for IC be programs and convert them into practical assessment tools, evidence expectations, implementation guidance and readiness criteria.
• Design and facilitate structured self‑assessments, leadership reviews, mock tracers, audits and validation sessions with multidisciplinary and frontline participation.
• Calibrate compliance ratings using current‑state practice and objective evidence; challenge unsupported “met” or “not applicable” ratings and document rationale for final determinations.
• Coordinate partner‑facing accreditation readiness for TCUs, including alignment with hospital‑partner expectations without creating avoidable duplication of survey effort.

• Identify compliance gaps, operational risks and evidence weaknesses; assess priority, impact and level of effort; and upscale material risks promptly.
• Lead development of corrective and preventive action plans (CAPAs), Plans of Correction and program‑level gap action plans with clear owners, milestones, evidence requirements and closure…