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Job Description

Manager Regulatory Compliance
Date: 08/27/2009
Location: Hazel Crest, IL
Facility:SOUTH SUBURBAN HOSPITAL
Manager Regulatory Compliance - 27340 		Apply Now
Bachelors degree in healthcare related field, Masters degree preferred.

7-10 years experience in healthcare regulatory management

Registered Nurse license if appropriate

Excellent organization, planning and delegation skills

Demonstrated knowledge in regulatory compliance, and HIPAA

Results oriented with concern for appropriate process

Job Description:

To coordinate, plan and manage the operational activities, administrative functions, personnel and resources in the area of regulatory compliance in order to reduce risk and ensure that customer needs are met in the safest, most cost-effective manner according to established standards of care and practice.

A. Manages the hospital's and SNF's Regulatory and Accreditation process, creating a climate of survey readiness. Serves as the site expert for interpretation of standards and is directly responsible for regulatory compliance with JCAHO, OSHA, CMS, IDPH, CDC and other broad regulatory agencies as appropriate. 30 %
1. Facilitates the coordination of visits, both announced and scheduled by regulatory agencies and serves as site representative.

2. Maintains up-to-date knowledge of all pertinent standards to which the hospital is accountable.

3. Reviews standards and literature, monitors regulatory websites and consults with external sources as necessary to keep current with changes in standards and regulations.

4. Ensures dissemination of regulatory standards information to associates and physicians.

5. Participates in all Advocate and site committees related to accreditation activities. Serves as chair of site Regulatory Readiness Team.

6. Maintains appropriate interagency networks to facilitate timely communications regarding regulatory changes.

7. Leads investigative activities and corrective actions that address actual and potential patient safety and regulatory issues to ensure minimum risk to patients in the organization as indicated.

8. Develops and implements an overall compliance plan that identifies accountabilities, training and educational requirements and unannounced survey procedures.

9. Establishes mechanisms to access and document the hospital and SNF level of compliance with standards.

10. Develops, implements and monitors the response plan when non-compliance issues are identified.

B. Accountability A continued... 0 %
1. Provides direct leadership to process teams that re-design and implement strategies to address non-compliance issues.

2. Directs organization-wide communication strategies related to regulatory agency compliance and survey visits.

3. Ensures maintenance of all files and information for accreditations.

C. Provides regulatory support and guidance for the design and implementation of the Safety, EOC and Infection Control programs within the hospital. 30 %
1. Develops annual Regulatory Readiness Plans, in conjunction with hospital leadership.

2. Serves as regulatory liaison to various external organizations to whom the hospital is accountable for patient safety issues, including JCAHO and IDPH.

3. Participates and provides leadership, as assigned to the hospital's Environment of Care/Safety Committee, Pharmacy & Therapeutics Committee, Ethics Committee, Medication Safety Committee and Infection Control Committee.

4. Ensures ongoing education of associates and physicians related to regulatory requirements including safety and infection control related regulatory compliance.

5. Apprises the executive team of key regulatory or safety related regulatory issues that arise within the hospital.

6. Directs investigative activities and corrective actions as assigned that address actual and potential regulatory non-compliance, issues, to assure minimal risks to patients and the organization.

7. Works with Patient Safety and Risk to ensure timely root cause or apparent cause analysis of significant patient safety events and manages corrective action plans. Conducts failure mode and effects analyses in collaboration with hospital and medical leadership.

8. .

D. Establishes the overall design and organization of policies and procedures and assists department leaders in development and revision of operational policies that are clear, concise and readily understood by associates. 5 %
1. Serves as primary gatekeeper for policy approval and intranet placement.

2. Establishes policy structure and content guidelines.

3. Identifies opportunities for consolidation of multiple policies into single standards of care, and resolves inconsistencies between policies, procedures and other governing documents.

4. Coordinates the review of all policies prior to administrative approval, and ensures collaboration between department directors in the development of policies that define responsibilities of multiple departments.

5. Ensures that the practice standards agreed upon by the clinical leaders and the clinical committees are documented clearly in policies.

E. Serves as site HIPAA Privacy Coordinator 5 %
1. Ensures compliance to HIPAA standards.

2. Reviews standards and current literature and consults with Advocate and external resources to identify areas in need of improvement.

3. Develops and implements a privacy compliance plan that identifies accountabilities, training, monitoring and reporting requirements.

4. Provides reports of status/action plans to Business Conduct Committee

F. Provides leadership support in the continued planning, development and implementation of goals and objectives, which further regulatory and organizational safety involving quality, clinical and operational excellence, patient satisfaction and patient safety at South Suburban Hospital. 10 %
1. As assigned participates or leads in committees and meetings as assigned, such as, but not limited to: • Performance Improvement/Patient Safety Committee • Medication Safety Committee • Medical Departmental meetings • Medical Records Committee • Professional Nursing Practice Committee • Infection Control Committee • Environment of Care Committee • Safety Committee

2. Participates in system Regulatory Committees and initiatives.

3. Partners with Quality and Risk in ensuring optimal organizational safety and patient advocacy.

4. Partners with Quality and Clinical areas to ensure compliance with JCAHO National Patient Safety Goals.

G. Development and ongoing maintenance of collaborative relationships with department managers/directors, physicians, system-wide contacts, and related external contacts in order to meet program objectives. 5 %

H. Plans, organizes and directs the operational activities of regulatory. 15 %
1. Plans and directs the administrative and operational functions to meet regulatory requirements and enhance patient safety.

2. Prepares and administers the departmental operating and capital budgets to ensure sufficient funds and personnel to accomplish departmental objectives within approved financial guidelines.

3. Monitors productivity levels and work functions to ensure proper staff and resource utilization.

4. Identifies areas for operations efficiency improvement and implements changes.

5. Interviews, hires, develops and evaluates departmental associates.

6. Approves the performance standards and competency for department level staff, assesses pertinent records, reports and contracts and takes appropriate action.
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