Overview
Kalamazoo Behavioral Health Hospital is seeking a Director of Regulatory Compliance & Patient Experience – RN to lead facility-based efforts in regulatory compliance, risk management, patient safety, and patient and family experience. This highly visible leadership role works collaboratively with hospital leadership, physicians, staff, patients, and families to identify and address risks, promote a culture of safety and accountability, and ensure ongoing regulatory readiness. The Director uses clinical expertise and sound judgment to drive meaningful improvements in patient care, safety, and the overall patient experience.
Benefits of joining NPH
- Competitive pay rates
- Medical, Dental, and Vision Insurance
- NPH 401(k) plan with up to 4% Company match
- Employee Assistance Program (EAP) Programs
- Generous PTO and Time Off Policy
- Special tuition offers through Capella University
- Work/life balance with great professional growth opportunities
- Employee Discounts through LifeMart
Responsibilities
- Implement and maintain a comprehensive facility-wide risk management program in collaboration with the Corporate Director of Quality and Compliance.
- Identify, investigate, analyze, and trend actual and potential risks involving patients, employees, visitors, clinical care, and facility operations.
- Lead or coordinate investigations of significant incidents, adverse events, near misses, complaints, grievances, and other potential exposures; ensure timely escalation and follow-through.
- Promote a culture of safety and effective incident reporting; educate staff on risk identification, reporting, mitigation, and prevention.
- Collaborate with facility leadership and corporate resources to assess potential liability, legal exposure, reportability, and regulatory notification when significant events occur.
- Develop and maintain systems that support patient safety, proactive risk reduction, and continuous regulatory readiness.
- Conduct routine and targeted facility rounds, tracers, audits, and mock surveys to identify clinical, environmental, operational, and regulatory vulnerabilities before they become adverse events or findings.
- Use RN clinical judgment during rounding and event review to identify patient-safety and care-delivery concerns and promptly escalate nursing or medical issues to the appropriate clinical leader.
- Partner with the Director of Nursing on nursing-related risk and readiness issues without assuming operational authority for nursing services.
- Review complaints and grievances for patient-safety, regulatory, clinical, legal, and reputational exposure; coordinate timely service recovery and follow-through with patients and families.
- Maintain a highly visible and accessible presence for patients and families and conduct proactive rounding to identify concerns early and prevent avoidable escalation.
- Coordinate Root Cause Analyses and other structured reviews for specified events; develop corrective and preventive actions and monitor effectiveness.
- Lead or coordinate the facility Safety Committee and support QAPI activities using incident, complaint, grievance, survey, environmental, and other risk data.
- Maintain continuous survey readiness and serve as a key facility resource during state, federal, accreditation, complaint, validation, and follow-up surveys.
- Coordinate survey requests, documentation, communication, and follow-up activities in partnership with facility and corporate leadership.
- Assist in development of Plans of Correction and regulatory responses; track corrective actions, evidence of implementation, and sustained compliance through closure.
- Identify repeat deficiencies, recurring events, high-risk patterns, and ineffective corrective actions and escalate them to facility and corporate leadership.
- Monitor facility cleanliness, organization, environment of care, safety, and overall presentation; ensure identified issues are assigned, corrected, verified, and sustained.
- Serve as a resource for risk management, patient experience, performance improvement, policy/procedure development, regulatory readiness, and compliance initiatives; provide regular reporting to facility and corporate leadership.
- Perform other duties and responsibilities as assigned.
Qualifications
- Bachelor's degree in Nursing (BSN) or related healthcare field required. Master's degree in Nursing, Healthcare Administration, Quality, Risk Management, or related field preferred.
- Minimum two years of experience in healthcare risk management, quality, patient safety, regulatory compliance, or nursing leadership required. Behavioral health or inpatient psychiatric experience strongly preferred.
- Experience with state, CMS, Joint Commission, DNV, or other applicable surveys required; supervisory experience preferred.
- Current, active, unrestricted Registered Nurse (RN) license in the state of employment or appropriate multistate privilege required.
- Strong knowledge of risk management, patient safety, incident investigation, root cause analysis, regulatory and accreditation standards, complaint and grievance management, service recovery, and performance improvement.
- Ability to identify clinical and operational risks, analyze trends, develop effective corrective actions, and monitor for sustained compliance.
- Excellent written and verbal communication, conflict resolution, organizational, problem-solving, and follow-through skills.
- Ability to build effective working relationships with patients, families, staff, providers, executive leadership, corporate/legal resources, and regulatory representatives.
- Comfortable maintaining a highly visible, hands-on presence throughout the facility and addressing concerns proactively and professionally.
