Regulatory Readiness Program Manager

Job Profile Summary

This role focuses on developing and implementing programs to establish, maintain, and improve patient quality care standards. In addition, this role focuses on performing the following Performance Improvement/Quality duties: Identifies and executes performance improvement and quality opportunities across the enterprise, enabling successful transformations and driving cost savings, process and product quality, and achievement of business goals. Responsibilities also include partnering with business leaders to provide expert insight on existing processes and procedures, applies process improvement methodologies to achieve PI/Quality objectives, and builds process improvement capabilities. A professional individual contributor role that may direct the work of other lower level professionals or manage processes and programs. The majority of time is spent overseeing the design, implementation or delivery of processes, programs and policies using specialized knowledge and skills typically acquired through advanced education. A senior level role that requires advanced knowledge of job area typically obtained through advanced education and work experience. Typically responsible for: managing projects / processes, working independently with limited supervision, coaching and reviewing the work of lower level professionals, resolving difficult and sometimes complex problems.

Job Overview

This position leads efforts to ensure continuous organizational compliance and ongoing survey readiness with clinical quality and patient safety standards and regulations required by The Joint Commission (TJC), Massachusetts Department of Public Health (DPH), Center for Medicare and Medicaid Services (CMS) and other regulatory agencies as needed. In this role, the Manager proactively plans, implements, and coordinates continuous improvement and readiness efforts related to regulatory surveys. Acts as a resource across the organization, overseeing complex projects to completion, facilitating teams engaged in regulatory readiness efforts, collaborating with leaders and staff, and is a role model and expert in team training, change management theory, and regulatory standards.This transformational leadership role focuses on the following:

- Continuous safety and quality improvement efforts and/or initiatives;

- Direct and collegial oversight and/or support specific to ongoing accreditation and regulatory requirements during and after the completion of on and off-site surveys;

- Subject matter expert in accreditation and regulatory requirements;

- Leads collaborative and collegial system wide rounding efforts to identify, recommend facilitate and support horizontally and vertically within the healthcare system to ensure continuous alignment with accreditation and regulatory requirements.

Job Description

Minimum Qualifications:

1. Bachelor's degree.

2. Three (3) years of experience in healthcare leadership, Regulatory, Quality, and Patient Safety.

Preferred Qualifications:

1. Master's degree.

2. Certified Professional in Healthcare Quality (CPHQ).

3. Five (5) years of experience in healthcare leadership, Regulatory, Quality and Patient Safety.

Duties and Responsibilities: The duties and responsibilities listed below are intended to describe the general nature of work and are not intended to be an all-inclusive list. Other duties and responsibilities may be assigned.

1. Serves as the organizational expert for The Joint Commission, DPH and CMS standards, regulations, and Conditions of Participation (CoPs).

2. Responsible for the interpretation and communication of regulatory requirements throughout the organization.

3. Provides education and consultation to administrative and clinical leadership, staff and faculty regarding the requirements of accreditation and regulatory organizations, using both formal and informal venues, e.g. presentations, publications, email, computer-based methods.

4. Provides guidance and assistance to departments, sections, units, and programs regarding improvements needed to monitor and ensure compliance with regulations & standards for TJC, DPH and CMS.

5. Provides informal consultation and advice to assist administrative and clinical leaders and their departments in improving performance.

6. Builds effective, supportive, and productive relationships with leadership, staff and faculty.

7. Facilitates development of tools, policies, procedures, and learning aids to promote compliance with standards.

8. Provides timely communication regarding new and revised standards and interpretations to administrative and clinical leadership, staff and faculty.

9. Works closely and builds effective working relationships with accreditation and regulatory agencies.

10. Responsible for all aspects of the plan to ensure continuous readiness with clinical regulatory and accreditation requirements.

11. Responsible for communication of the continuous readiness plan to leadership and key groups.

12. Works closely with Patient Safety/Risk Management, Quality Improvement and Data Analytics including coordination of the Joint Commission Performance Improvement and NPSG standards compliance.

13. Leads a coordinated response to unannounced external accrediting or regulatory agency visits such as DPH, Joint Commission or CMS.

14. Works with Patient Safety/Risk Management on an as-need basis to support BORM and DPH requirements regarding reporting of adverse events.

15. Stays current with new standards.

16. Develops, coordinates, and implements all aspects of the annual continuous readiness plan.

17. Performs ongoing assessment of the readiness plan.

18. Identifies needed improvements.

19. Prepares and implements action plans to achieve needed improvement and compliance.

20. Provides ongoing communication with regulatory agencies regarding survey and readiness activities.

21. Completes annual TJC application.

22. Supports response to agency requests for revision and corrective action plans.

Physical Requirements:

1. This is largely a sedentary role, which involves sitting most of the time, but may involve movements such as walking, standing, reaching, ascending/descending stairs, and operating office equipment.

2. Frequently required to speak, hear, communicate, and exchange information.

3. Ability to see and read computer displays, read fine print, and/or normal type size print and distinguish letters, numbers and symbols.

4. Requires manual dexterity using fine hand manipulation to operate computer keyboard.

Skills & Abilities:

1. Outstanding team player.

2. Ability to develop effective relationships with a broad array of people from diverse backgrounds.

3. Strong interpersonal skills.

4. Superior organizational skills to manage a large volume of incoming data, information, reports, etc. in paper and electronic formats.

5. Ability to create and deliver appealing and compelling presentations to a variety of audiences including clinicians, staff, faculty, administration and governance groups.

6. Excellent written and verbal communication skills.

7. Demonstrated skill in change management and quality improvement.

8. Knowledge of clinical terminology.

9. Strong computer skills including Microsoft Office platform.

10. Ability to learn and effectively use computer software, such as electronic health records and data entry.

11. Flexibility in work schedule.

12. Project management skills.

13. Ability to establish supportive, collegial relationships.

At Tufts Medicine, we want every individual to feel valued for the skills and experience they bring. Our compensation philosophy is designed to offer fair, competitive pay that attracts, retains, and motivates highly talented individuals, while rewarding the important work you do every day.

The base pay ranges reflect the minimum qualifications for the role. Individual offers are determined using a comprehensive approach that considers relevant experience, certifications, education, skills, and internal equity to ensure compensation is fair, consistent, and aligned with our business goals.

Beyond base pay, Tufts Medicine provides a comprehensive Total Rewards package that supports your health, financial security, and career growth-one of the many ways we invest in you so you can thrive both at work and outside of it.

Pay Range: