Manager – Regulatory and Quality

Education and Work Experience:

• Bachelor's degree in nursing, business administration, hospital administration or equivalent combination of education/related experience: Required
• Three years' experience in accreditation or regulartory compliance and in quality, patient safety, or performance improvement: Required
• Clinical background: Required
• Five years' experience in healthcare accreditation and regulatory affairs with a successful track record of effective accreditation and regulatory affairs activities and outcomes: Preferred
• Two years' leadership experience in regulatory, quality, patient safety, performance improvement, or healthcare administration: Preferred

Licenses/Certifications:

• Lean or Six Sigma Green Belt or GE Change Management certification: Required within two years of hire
• Lean or Six Sigma Green Belt (LGB) or PROSCI-CCMP: Required

Essential Functions:

• Partners with system, network, and site leadership to align regulatory compliance programs with organizational strategy, quality initiatives, patient safety priorities, and risk reduction goals. Partners with clinical and non-clinical staff to develop, implement, monitor and improve structures required to achieve high quality, safe, cost-effective health care. Assists managers and leaders to mobilize various teams throughout the organization to ensure continuous accreditation standards compliance. Coordinates contract renewal and oversight activities associated with regulatory compliance monitoring system. Provides leadership and expertise in the pursuit and attainment of organizational goals related to accreditation, licensing and regulatory compliance. Manages a team of professionals who collectively safeguard facility licensing status, maintain accreditations/certifications, and assure compliance with a vast range of healthcare regulations. Supports the accreditation preparation process for the organization by managing logistics, conducting mock surveys and maintaining organization's communication regarding changes and updates for regulatory compliance.
• Conducts annual State regulatory compliance assessment. Develops and maintains any action plan and response to citations for any regulatory agency. Collects data and prepares graphic presentation, and compiles reports to demonstrate compliance. Reviews, interprets and assists hospital departments, leadership and Medical Staff in the implementation of Federal, State and Joint Commission standards and regulations.
• Manages daily operations of quality, patient safety, Regulatory and performance improvement programs. Supervises and develops Quality/PI , regulatory and patient safety staff, providing mentorship, performance feedback, and coaching. Ensures alignment of local activities with system strategic priorities.
• Leads patient safety initiatives, including root cause analyses, proactive risk assessments, and corrective action follow-up. Manages site's event reporting and learning systems, ensuring timely review, investigation, and communication of findings. Promoted a culture of safety and just culture principles within assigned entity or service line.
• Facilitates and oversee improvement projects to reduce harm, improve clinical outcomes, and enhance operational efficiency. Applies Lean, Six Sigma, and other performance improvement methodologies methodology and provide coaching to leaders and teams on PI tools and techniques. Monitors project outcomes and ensure sustainability of improvements. Ensures timely collection, validation, and reporting of quality, safety, and regulatory metrics. Prepares and presents data to entity leaders, committees, and boards, translating findings into actionable improvement opportunities. Partners with system Quality and regulatory team and Patient Safety on benchmarking and external reporting requirements. Provides training and mentorship to staff on patient safety, and quality improvement methods. Fosters interdisciplinary collaboration to improve workflows and outcomes.
• Performs other job-related duties as assigned.

Organizational Requirements:

Adventist Health is committed to the safety and wellbeing of our associates and patients. Therefore, we require that all associates receive all required vaccinations as a condition of employment and annually thereafter, where applicable. Medical and religious exemptions may apply.

Adventist Health participates in E-Verify. Visit https://adventisthealth.org/careers/everify/ for more information about E-Verify. By choosing to apply, you acknowledge that you have accessed and read the E-Verify Participation and Right to Work notices and understand the contents therein.