Employment Type:

　　Full time

　　Shift:

　　Day Shift

　　Description:

　　The Regulatory Quality Manager coordinates and facilitates the hospital regulatory compliance ensuring the highest quality and patient safety activities. The Regulatory Quality Manager oversees the Joint Commission Accreditation/Certification for the hospital and acts as a consultant for all certification, accreditation, and regulatory programs. Also, ensures all state regulatory activities and compliance are maintained. Manages and directs day-to-day regulatory compliance work activities for TJC certifications inclusive of Stroke & Sepsis. Engages in performance improvement projects to support Saint Francis Health priorities in fulfilling the vision and mission that lead to regulatory compliance, high quality organization, patient safety, and operational excellence. Regulatory Quality Manager helps supports and oversees the Quality team and Patient Safety/Risk Management to support zero harm activities. Regulatory Quality Manager also helps support maintaining highest level of compliance with other organizations such as Leapfrog, IBM Watson, and others that impact quality and patient safety. Utilizes quality methodology to educate staff and departments in continuous performance improvement and regulatory compliance, concepts, processes, and tools. Works with and oversees the Quality Department to collect and track data inclusive of analysis and action plans utilizing Lean Methodology to improve outcomes and compliance. Participates in quality rounds, co-chairs Quality/Safety Committees and help reports data as required for regulatory programs. The Regulatory Quality Manager reports to, works in concert with, and supports the Regional Director of Quality and Safety.

　　Coordinates and facilitates maintaining hospital regulatory compliance ensuring the highest quality and patient safety activities.

　　Oversee Joint Commission Accreditation and act as a consult for all certification, accreditation, and regulatory programs.

　　Manages and directs day-to-day regulatory compliance work activities such as regulatory rounds.

　　Helps supports and oversees the Quality team and Patient Safety/Risk Management to support zero harm activities.

　　Provides assistance and acts as a resource to functional departments and business units identifying, scoping, planning, and implementing performance improvement projects.

　　Participates in quality rounds, co-chairs Quality/Safety Committees and help reports data as required for regulatory programs.

　　Maintains a working knowledge of applicable Federal, State, and Local laws and regulations, as well as other policies and procedures in order to ensure adherence in quality and safety.

　　Helps to identify problems, offer solutions, and participate in their resolution regarding quality and safety events

　　Minimum Qualifications (Education/Experience/Licensure/Certification/Skills):

　　RN Licensure-Bachelor’s degree in Nursing required.

　　BLS certification required.

　　Master’s Degree preferred in nursing, business, or healthcare.

　　CPHR Certification preferred

　　Minimum of five years of acute care hospital clinical care experience required.

　　Minimum of five years of managerial, quality, or regulatory experience preferred.

　　Strong interpersonal and communication skills. Demonstrated presentation and facilitation skills. Must be able to work independently and on a team. Has the ability to use problem-solving, critical thinking and priority setting skills. Knowledge of Microsoft Office, data base management, spreadsheets, internet skills and e-mail.

　　Other qualifications include role model and mentor for staff, attends relevant education offerings and meetings, identifies own self-development goals and time frame, upholds the mission, vision and values of the organization, assists with and participates in activities and programs with other organizations as appropriate.

　　Our Commitment to Diversity and Inclusion

　　Trinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and inclusion in all that we do. Our colleagues have different lived experiences, customs, abilities, and talents. Together, we become our best selves. A diverse and inclusive workforce provides the most accessible and equitable care for those we serve. Trinity Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by law.

　　Our Commitment to Diversity and Inclusion

　　Trinity Health is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians across 25 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.

　　Our dedication to diversity includes a unified workforce (through training and education, recruitment, retention, and development), commitment and accountability, communication, community partnerships, and supplier diversity.

　　EOE including disability/veteran