Massachusetts Green Jobs

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Job Type:

Regular

Scheduled Hours:

40

Work Shift:

Day (United States of America)

Under the direction of the Chief Quality Officer, the Director, Regulatory Affairs directs the strategic management and planning for the Joint Commission (TJC) and accreditation related activities for clinical services throughout Lahey Hospital & Medical Center (LHMC), including all sites under LHMC’s license.

The Director, Regulatory Affairs develops a comprehensive accreditation program to ensure: 1) LHMC complies with all federal, state and TJC standards; 2) all administrative and clinical leaders are kept abreast of state, federal and Joint Commission requirements; 3) requirements are audited and reported on a systematic basis, and 4) that opportunities for improvement are identified, communicated and monitored.

The Director also oversees and supports all regulatory communications and on site regulatory visits. The position requires expert knowledge in federal, state and TJC standards and clinical and operational expertise to achieve and maintain a continuous state of readiness. This includes, but is not limited to, functioning as an expert resource and consultant to the organization, as a liaison between the organization and accreditation or regulatory bodies, and as a resource in continuous improvement activities.

The Director, Regulatory Affairs works directly with the executive leadership, clinical and administrative leadership, and supports colleagues in all roles across the organization.

Job Description:

Essential Duties & Responsibilities, including but not limited to:

1) Develops and implements a continuous readiness plan, which includes activities that support, at a minimum: efforts to ensure ongoing assessment of compliance ; communicating accreditation/regulatory information to all levels of the organization; consulting on and interpreting standards; providing staff education and training; overseeing continuous readiness auditing and improvement processes for identified readiness priorities; coordinating, facilitating and responding to on-site surveys.

2) Directs all organizational continuous readiness/accreditation activities including but not limited to: serving as primary contact for TJC communication; managing operational aspects of accreditation applications; completing and submitting all JC accreditation process requirements; participating in ongoing standards assessment and the development of action plans for prioritized risks; reporting individual and system wide opportunities for improvement to operational managers and clinical and administrative leaders.

3) Coordinates formal accreditation, regulatory or licensure on-site surveys. Develops and maintains a logistics plan for survey execution. Acts as the primary liaison with the survey team. Coordinates the development, implementation and monitoring of corrective action plans in response to TJC surveys. Collaborates with Risk Management and Patient Safety to assist in on-site surveys and in the development, implementation and monitoring of CMS or state surveys.

4) Provides consultative services to all levels of the organization on accreditation/regulatory issues, interpretation of standards and policies, and linkage to clinical and operational processes.

5) Educates the organization and staff by leading readiness steering and management teams: integrating elements of ongoing readiness into leadership meetings, resident orientation, and committee meetings. Reinforcing systems or processes that support the delivery of safe, high quality, patient-centered care.

6) Mentors leaders, accreditation liaisons and colleagues on the adoption and use of tools for patient tracers, assessments, data collection, analysis and improvement.

7) Partners with Quality & Safety and Risk & Patient Safety to leverage opportunities to sustain compliance with best practices as part of existing improvement teams.

8) Collects, aggregates, analyses and communicates data and information associated with current accreditation readiness.

9) Participates on hospital wide committees, reviewing policies and practices for congruence with applicable practice standards.

10) Facilitates a collaborative network wide approach to regulatory compliance.

11) Works with Clinical and Administrative leaders and identifies need for action based on data analysis identified in key areas of the organization.

12) Ensures requirements of external agencies are met.

13) Serves as primary liaison with regulatory agencies and coordinates all communications with regulatory agencies

14) Incorporates Lahey Hospital & Medical Center (LHMC) Guiding Principles into all activities.

15) Complies with all Lahey Hospital & Medical Center policies.

16) Complies with behavioral expectations of the department and Lahey Hospital & Medical Center.

17) Maintains respectful and effective interactions with colleagues and patients.

18) Demonstrates an understanding of the job description, performance expectations, and competency assessment.

19) Demonstrates a commitment toward meeting and exceeding the needs of our customers and consistently adheres to Customer Service standards.

20) Participates in departmental and/or interdepartmental quality improvement activities.

21) Participates in and successfully completes Mandatory Education.

22) Performs all other duties as needed or directed to meet the needs of the department.

Minimum Qualifications:

Education:

• Masters in Science in a health-related field or an MBA with healthcare experience.

Licensure, Certification, Registration:

• Not required.

Skills, Knowledge & Abilities:

• Must have (a) excellent oral and written communications skills, (b) experience in teaching and consulting, and (c) flexibility and creativity in problem solving.

• Must have working knowledge of The Joint Commission Hospital standards, The CMS Hospital Conditions of Participation and Massachusetts State Licensure regulations.

Experience:

• Five to seven years of clinical and/or administrative experience with specific experience related to accreditation and regulatory bodies, such as The Joint Commission, CMS and state licensing agencies.

• Prior experience in regulatory affairs is preferred.

FLSA Status:

Exempt

As a health care organization, we have a responsibility to do everything in our power to care for and protect our patients, our colleagues and our communities. Beth Israel Lahey Health requires that all staff be vaccinated against influenza (flu) and COVID-19 as a condition of employment. Learn more (https://www.bilh.org/newsroom/bilh-to-require-covid-19-influenza-vaccines-for-all-clinicians-staff-by-oct-31) about this requirement.

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Equal Opportunity Employer/Veterans/Disabled