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Director, Regulatory Operations

Company: JPS Health Network
Location: Fort Worth
Posted on: October 19, 2020

Job Description:

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 people.

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 performance

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 www.teamacclaim.org.

Job Description:

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 incidents.

Typical Duties:

* 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 Network.
* In collaboration with the Chief Quality Officer and Executive Director of Quality Operations and Implementation, works with key Network stakeholders regarding continuous survey readiness activities.
* 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 compliance.
* Provides education and updates related to regulatory compliance.
* Manages patient grievance follow up reported through accreditation agencies.
* 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 standards.
* 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 procedures.
* Performs other related job duties as assigned.

Qualifications:

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 accredited university
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)

Location Address:

1400 S. Main Street

Fort Worth, Texas, 76104

United States

Keywords: JPS Health Network, Fort Worth , Director, Regulatory Operations, Executive , Fort Worth, Texas

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