Sys Director Regulatory Readiness

ESSENTIAL KEY JOB RESPONSIBILITIES
1. Responsible for planning, implementation and evaluation of large and complex program initiatives to improve the
performance, quality of care and reduce the risk of patient harm, adverse regulatory decisions and assessed
regulatory penalties
2. Oversee the division and hospital implementation of the regulatory readiness standardized plan. Establish the
mechanism to provide ongoing evaluations to veridate regulatory readiness.
3. Establish and lead the regulatory readiness electronic monitoring (for example, Sentact, etc.) process and chair the
Advisory Group to expand the library of electronic tools, patient tracers and monitoring process.
4. Ability to achieve organizations goals, motivate and move hospital operational clinical and administrative leadership,
physician enterprise, and clinicians to improve performance, patient safety and regulatory compliance initiatives.
5. Demonstrates analytical ability in evaluating complex patterns of practice, operations, and departmental functions
that contribute to or hinder efficient patient safety and regulatory readiness initiatives.
6. As a part of the Department of the CMO, influences the business initiatives, strategies and objectives while
complying with the federal, state and agency laws and regulations.

Page 1 of 8 JOB DESCRIPTION MASTER TEMPLATE

JOB DESCRIPTION

7. Support leadership at the divisions, hospitals and clinics to achieve their goals of full regulatory compliance and
sustain a state of constant readiness
a. Provide education, on line resources, consultation on the interpretation of regulations as it applies to the
survey process
b. Coordinate assessments of hospitals and clinics for adherence to regulations and readiness for external
compliance surveys
c. Assist the division or entity in the recovery phase should the entity be deemed as noncompliant after an
external survey

8. Support (or lead) various work groups to ensure regulatory compliance and patient safety initiatives
a. Serve on various task forces, ad hoc committees, participate on work groups and committees to provide
direction and consultation on regulatory compliance activities
b. Lead special task forces/work groups on specific system wide projects to facilitate a standardized approach
to regulatory compliance

9. Develop and distribute tools, resources and additional strategies in partnership with the division leads that align with
the CSH regulatory and patient safety strategies. In addition, support the divisions, hospitals and clinics in the
implementation of the CSH regulatory readiness strategies to maintain a continuous survey readiness and full
compliance with law and regulations
10. Promote the principles of patient safety and quality in the strategies developed for regulatory readiness
11. Participate in partnership with the System Vice President Regulatory Readiness, the most efficient and effective
utilization of system offices resources in the support of regulatory readiness for the various divisions and entities
a. Consider the use of on line resources and services
b. Consider and communicate the system wide model for obtaining/sustaining constant regulatory readiness at
CommonSpirit Health

• Bachelor's degree in a healthcare-related field required.
• Master’s Degree or higher in a related field preferred. A minimum of five (5) years of clinical, patient care leadership experience or healthcare related equivalent 
• A minimum of seven (7) years of experience in the discipline with progressive management responsibility in a health care setting/system, two (2) of which is related to managing an acute care organization’s Quality Improvement, Patient Safety, Regulatory Program or related program. 
• Experience in developing and implementing clinical, service and operational process improvement initiatives, both small and large scale. 
• Strong critical thinking and communication skills.
• Ability to summarize complex information succinctly.
• Skilled in facilitating geographically disperse teams.
• Knowledge and expertise in specific performance improvement/CQI methodologies (e.g. Six Sigma, LEAN). 
• Current substantial knowledge of accreditation and regulatory requirements for acute and ambulatory care services (e.g. state, federal, local regulations; Joint Commission, etc.).
• Detailed oriented.
• Financial and Quantitative Acumen
• Possess extensive knowledge in healthcare regulations, quality management and performance improvement, patient safety and risk management principles
• Demonstrate advanced knowledge and understanding of the regulatory landscape, including strategies to ensure the organization is aligned with the regulatory and accreditation requirements for successful completion of the certification, accreditation and licensure survey processes
• Strong analytical, organizational, and problem-solving skills, with ability to identify system vulnerabilities and develop and apply innovative solutions
• Strong leadership, interpersonal and communications skills to promote regulatory compliance across all levels of the organization
• Strong ability to convey complex information clearly and concisely to all levels of staff, management, and outside personnel, with the ability to motivate and influence others
• Highly adaptive and ability to manage multiple priorities 
• Strong leadership skills with the ability to create a goal-oriented climate of teamwork and collaboration in the achievement of objectives
• Knowledge of relevant healthcare information technology
• Proficiency in Microsoft Word, Excel, PowerPoint, and Outlook
• High Integrity/Ethics/Trust

Inspired by faith. Driven by innovation. Powered by humankindness. CommonSpirit Health is building a healthier future for all through its integrated health services. As one of the nation’s largest nonprofit Catholic healthcare organizations, CommonSpirit Health delivers more than 20 million patient encounters annually through more than 2,300 clinics, care sites and 137 hospital-based locations, in addition to its home-based services and virtual care offerings. CommonSpirit has more than 157,000 employees, 45,000 nurses and 25,000 physicians and advanced practice providers across 24 states and contributes more than $4.2 billion annually in charity care, community benefits and unreimbursed government programs. Together with our patients, physicians, partners, and communities, we are creating a more just, equitable, and innovative healthcare delivery system.