CommonSpirit Health was formed by the alignment of Catholic Health Initiatives (CHI) and Dignity Health. With more than 700 care sites across the U.S. from clinics and hospitals to home-based care and virtual care services CommonSpirit is accessible to nearly one out of every four U.S. residents. Our world needs compassion like never before. Our communities need caring and our families need protection. With our combined resources CommonSpirit is committed to building healthy communities advocating for those who are poor and vulnerable and innovating how and where healing can happen both inside our hospitals and out in the community.

This is a remote position and will require travel. 

This position is responsible for providing system wide direction and support to the hospitals, clinics and national office in the interpretation and compliance of regulations from primarily the Center for Medicare and Medicaid Services (CMS), Accrediting Organizations (such as The Joint Commission (TJC), and other regulatory, accrediting organizations and state agencies. The regions, hospitals and clinics have primary responsibility for ensuring full compliance with all regulations that apply to their facilities and operations with the support and guidance of the National Regulatory Readiness Team.  The regions, hospitals, clinics and other CommonSpirit Health entities strive for full compliance with each of the CMS Conditions of Participation and minimal to zero findings with the accrediting organizations.  This position serves to support the hospitals and clinics in achieving full compliance, full certification and no notices of termination through the primary responsibilities outlined in the section below.This position interacts at many levels across the system, region, healthcare entities and through hospital leadership, hospital departments and service lines of business. 

Key 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 region and hospital implementation of the regulatory readiness standardized plan. Establish the mechanism to provide ongoing evaluations to validate 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.
7. Support leadership at the regions, hospitals and clinics to achieve their goals of full regulatory compliance and sustain a state of constant readiness
• Provide education, on line resources, consultation on the interpretation of regulations as it applies to the survey process
• Coordinate assessments of hospitals and clinics for adherence to regulations and readiness for external compliance surveys
• Assist the region 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
• Serve on various task forces, ad hoc committees, participate on work groups and committees to provide direction and consultation on regulatory compliance activities
• 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 region leads that align with the CSH regulatory and patient safety strategies. In addition, support the regions, 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 regions and entities
• Consider the use of on line resources and services
• Consider and communicate the system wide model for obtaining/sustaining constant regulatory readiness at CommonSpirit  Health

Education:

• Bachelor's degree in a healthcare-related field required.
• Master’s Degree or higher in a related field preferred.

Experience & Certification:

• 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. 

• Current State License in a clinical field required, ideally RN
• Certified Professional in Healthcare Quality (CPHQ), or Healthcare Quality and Management Certification (HCQM), or Certificate of Professional Healthcare Quality and Patient Safety (CPQPS) within 2 years of employment is required.
• 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. Has departmental budget accountability for travel related to providing facility support and workgroup/team participation.

Scope of Work

• National Leader with primary oversight of the implementation of the regulatory readiness standardized plan at the regional and hospital level.
• Accountable for projects as assigned (for example, facilitating the CSH Regulatory Sentact Advisory Team, and CSH Regulatory Standardization Program.
• Provides national support and guidance for other Departments (such as, Women, Infant, Pediatric Clinical Institute, EHR, Clinical Informaticists, etc.) as needed.
• Provides guidance for achieving, maintaining, and sustaining regulatory compliance in light of the current interpretation of the federal, state and accrediting standards and assists the division/hospital in the development of strategies and corrective actions when needed.
• Responsible for responding to CSH Key Stakeholders (such as, National Department/Region and hospitals in providing guidance based on law and regulation from a national perspective and locale as indicated.
• Availability for regulatory guidance required for CSH hospitals to meet the regulatory/accreditation requirements as required by law and regulation.