Position Purpose

Develops implements and maintains a comprehensive, organization-wide, ongoing regulatory and compliance readiness program. This position is responsible for assisting the Director of Quality, Patient Safety and Regulatory affairs with the coordination and oversight of regulations and standards governing the hospitals set forth by all Regulatory Agencies, evaluation activities and the survey process. This position also supports the work of the organization to build high reliability through a safety program. The position also supports quality and outcome measures to meet organizational goals.  The responsibilities include acting as a resource for staff by providing education and assistance regarding regulatory compliance, patient safety and quality and associated activities. Coordinates or participates in   all regulatory related meetings, and participates in preparatory regulation compliance meetings of various departments and programs. Coordinates or participates in patient safety committees and quality and outcome groups and requested by the Director. 

What you will do

• Support and facilitate hospital-wide ongoing compliance with regulatory standards including TJC surveys

• Serve as a contact with The Joint Commission and DPH

• Assist in maintenance of the plan for unannounced surveys

• Identify resources needed for standard compliance and ongoing readiness

• Provide assistance to the organizational program to sustain safety training and habits throughout the organization

• Assist the organization to use data to plan, deliver and evaluate patient safety in care and services

Minimum Qualifications

• Bachelor’s Degree in healthcare, or related field required

• At least 5 years current experience in a quality/regulatory and/or patient safety related role preferred

• RN preferred           

• Professional in Healthcare Quality (CPHQ)   

• Knowledge of regulatory requirements, patient safety initiatives and quality indicators as related to the hospital setting and the ability to relay pertinent information to staff.

Position Highlights and Benefits

• Full time 40hrs M-F days

• Excellent benefits - starting day 1!

Ministry/Facility Information

Saint Francis Hospitaliscommitted to exceeding the expectations of our patients and families by providing world-class service in a progressive, people-centered, compassionate health care environment. We are licensed for 617 beds and 65 bassinets, are a major teaching hospital and the largest Catholic hospital in New England.