Provides leadership and direction for entire organization regarding regulatory agencies and standards for the Hospital, home care, and outpatient areas. Manages the coordination of The Joint Commission, Colorado Department for Public Health and Environment (CDPHE), CMS and/ or other external agency surveys. Collaborates with other department-specific regulatory surveys as requested or required (i.e. Radiation, Centers of Excellence, Disease specific certification, etc.). The position leads the Hospital continuous readiness program including directing an ongoing tracer program and oversight of regulatory process improvement initiatives and education of chapter chairs, leadership and associates. The Manager of Regulatory Affairs is a proactive change agent for the organization around regulatory readiness and assists the organization in integration of new standards and requirements, along with identification of possible barriers and areas of noncompliance, planning mock surveys, and collaborating with system and other care site regulatory partners.
This position assists with strategic planning to align organizational goals with improvement initiatives and organizational need.
This position also collaborates with department and system partners in Risk, Patient Safety, Infection, Environment of Care/ Safety and Quality to ensure alignment of all regulatory work.
This position is also responsible for the organization�s reporting requirements of any safety events that may occur, along with the hospital�s annual licensure submissions and other unannounced complaint surveys from The Joint Commission, CDPHE or CMS, including resolution and follow up of any found deficiencies.
Lastly, this position demonstrates skills in facilitation, coaching, change management, and process improvement and acts as an internal consultant for all levels of the organization which includes strategic planning and coordination of the program, team and project management, and report outs to Senior Leadership and/ or Site Leadership with measurable outcomes. In addition, the position assists as requested with strategic planning to align organizational goals with improvement initiatives and organization need.
� Assures that Performance Improvement initiatives are evidenced-based and consistent with regulatory guidelines.
� Provides ongoing Orientation, Education and Training pertinent to Performance Improvement based on customer needs.
� Implements Performance Improvement methods to achieve desired outcomes.
� Provides Team facilitation to achieve optimal outcomes organizationally and departmentally
This Job Description details the essential functions of the position. The list below is also considered to be essential functions of your position and all employees within Exempla Healthcare are expected to meet the following in their day-to-day work:
1. Be available to work as scheduled and report to work on time
2. Be available to work overtime if needed
3. Be willing to accept supervision and work well with others
4. Be respectful of all with whom you interact and follow the SCL Health Partnership Behaviors
5. Be well groomed and dressed appropriately for your role
6. Be in compliance with the drug and alcohol policy as stated in the Employee Handbook
7. Be sufficiently rested to perform your duties throughout the period assigned
8. Demonstrates a willingness to learn
9. Be able to communicate clearly, think clearly, and concentrate on assigned tasks
QUALIFICATIONS AND EXPERIENCE
� Bachelor�s degree required, preferably in a health-related field.
� Demonstrated experience and competence in the application of Performance Improvement principles and process change.
� Preferred Management experience.
� Preferred Master�s Degree or 4 years of equivalent experience.
� Certification in Regulatory arena (or w/I 1 year of hire)
MATERIAL/ EQUIPMENT INVOLVED
Telephone, computer, copy machine, fax machine, audio-visual equipment, office equipment, other equipment as necessary
Joint Commission Intranet expert (w/I 1 year of hire)
HAZARDOUS EXPOSURE CATEGORY:
Involves no exposure to blood, body fluids, or tissues, although situations can be imagined or hypothesized under which anyone, anywhere, might encounter potential exposure to body fluids.
Light work. Exerting up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently, and/or a negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for sedentary work
� Addition to the responsibilities described above, the role may include such other responsibilities, and duties as assigned from time to time, based upon Exempla Healthcare needs or requirements.
� Must be able and willing to travel to other Exempla Healthcare sites as needed