Director, Regulatory Operations
Company: JPS Health Network
Location: Fort Worth
Posted on: October 19, 2020
JPS Health Network is a $950 million, tax-supported health care
system for Tarrant County in North Texas. Licensed for 578 beds,
the network includes an acute care hospital andmore than 40
community-based clinics, including19 school-based clinics. John
Peter Smith Hospital is home to Tarrant County's first and only
Level 1 Trauma Center, its only psychiatric emergency services site
and has the largest hospital-based family medicine residency
program in the nation. Our network employs more than 6,500
Acclaim is our multispecialty medical practice group. Acclaim has
over 300 providers serving the JPS Health Network in specialties
ranging from primary care to general surgery and trauma. The
Acclaim group has been formed around a common set of incentives and
expectations supporting the operational, financial and clinical
outcomes of the network. Our goal is to provide high quality,
compassionate clinical care for every patient, every time.
For more information, visit www.jpshealthnet.org.
To view all job vacancies, visitwww.jobs.jpshealthnet.org/ or
Description: The Director Regulatory Operations will provide
leadership and direction for both Regulatory Affairs and
Environment of Care/Life Safety (EOC/LS) for the Tarrant County
Hospital District. This position leads Regulatory Affairs, in
conjunction with Network leaders, in initiatives aimed at achieving
a continuous state of readiness surrounding licensure,
accreditation and certification programs, as well as ensuring
ongoing compliance with State and Federal rules/regulations and
performance improvement. The Director Regulatory Operations leads
Environment of Care/Life Safety activities, in conjunction with
Network leaders, in initiatives aimed at reducing EOC and LS
* Supports the Chief Quality Officer and Executive Director of
Quality Operations and Implementation in the establishment and
maintenance of a continuous survey readiness program at JPS Health
* In collaboration with the Chief Quality Officer and Executive
Director of Quality Operations and Implementation, works with key
Network stakeholders regarding continuous survey readiness
* Plans, implements, directs, evaluates and documents a continuous
survey readiness program for the organization.
* Facilitates mock surveys through tracer activities and annual
self-assessment activities through the Joint Commission.
* Establishes policies and procedures, identifies gaps and
participates in the formation of action plans related to regulatory
* Provides education and updates related to regulatory
* Manages patient grievance follow up reported through
* Submits applications, license renewals and regulatory
communications in a timely manner.
* Monitors compliance and training within The Joint Commission
standards related to Environment of Care (EOC), Emergency
Management (EM) and Life Safety (LS), known as the Physical
Environment. Interprets EOC and LS regulatory standards and
collaborates with key stakeholders to ensure compliance with these
* Oversees and monitors ongoing performance improvement for Safety
Management, Security Management, Hazardous Materials / Waste
Management, Fire Safety Management, Medical Equipment Management,
Emergency Management, Utility Management, and Life Safety.
* Provides direction and leadership to staff and Network leaders to
ensure compliance with the rules and regulations as set forth by
the Joint Commission (TJC), National Fire Protection Association
(NFPA), Occupational Safety and Health Administration (OSHA),
College of American Pathologists (CAP), Environmental Protection
Agency (EPA), state and local requirements through developed
policies and procedures for appropriate safety management
practices. Maintains current certifications, testing and
inspections for facilities.
* Ensures that a library of information is maintained regarding
inspection, testing and maintenance of the equipment and systems of
the JPS Health Network.
* Provides strategic direction and leadership on Safety/Hazardous
Materials and Waste/Fire and Life Safety Compliance, Safety and EOC
initiatives for the JPS Health Network.
* Plans and sets goals through the development of a Safety
Management Plan and helping organization succeed in having a
preeminent Safety culture.
* Monitors the effectiveness of changes in plan, policies and
* Performs other related job duties as assigned.
Required Education and Experience:
* Bachelors degree in Safety Engineering, Healthcare
Administration, Business Administration, Nursing or related field
from an accredited university
* 7 plus years of experience working in a Regulatory Affairs or
Environment of Care/Life Safety leadership role.
Preferred Education and Experience:
* Proven experience in successfully leading a large health system
through regulatory accreditation.
* Masters degree in Safety Engineering, Healthcare Administration,
Business Administration, Nursing or related field from an
Preferred Licensure/Certification/Specialized Training:
* Certified Healthcare Facility Manager (CHFM)
* Certified Hospital Safety Professional
* Certified Healthcare Emergency Professional (CHEP)
* Certified Professional in Healthcare Quality (CPHQ)
* Lean Six Sigma Green Belt Certification.
* Licensed Clinical Healthcare Professional (e.g. MD, RN)
1400 S. Main Street
Fort Worth, Texas, 76104
Keywords: JPS Health Network, Fort Worth , Director, Regulatory Operations, Executive , Fort Worth, Texas
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