Bachelor's degree in healthcare administration, nursing, or related field.
Five years of related work experience demonstrating job knowledge.
At least three years of management experience in an acute care setting, focusing on Quality, Safety, or Regulatory Programs.
Two years of clinical or patient experience.
Experience in developing and implementing clinical and operational process initiatives.
Responsibilities
Provide operational support for Patient Safety and Accreditation programs.
Coordinate comprehensive plans for patient safety across facilities.
Facilitate regulatory compliance activities via departmental rounds.
Implement policies and procedures and manage survey preparation.
Conduct training in response to compliance deficiencies.
Review and trend incident report information for quality assessments.
Guide management to achieve continuous readiness for licensure and accreditation.
Benefits
Access to a comprehensive network of healthcare services and support.
Opportunities for continuous professional development and education.
Work within a collaborative team environment committed to healthcare excellence.
Full Job Description
Job Summary and Responsibilities
As our Regulatory Compliance Program Manager, you will help ensure that all facets of patient safety are identified and integrated into comprehensive plans so that Virginia Mason Franciscan Health (VMFH) can provide the highest standards of patient care.
Every day you will facilitate on-going regulatory compliance activities through extensive rounding on clinical and non-clinical departments at VMFH.
Key Responsibilities Include:
Compliance Leadership: Ensure assigned hospitals and clinics are continuously aligned with The Joint Commission (TJC) standards and all applicable state and federal regulations.
Continuous Readiness Facilitation: Drive ongoing regulatory compliance activities through extensive rounding and engagement with both clinical and non-clinical departments across VMFH facilities.
Policy & Procedure Implementation: Oversee the effective implementation of policies and procedures to ensure regulatory adherence.
Survey Preparedness & Management: Lead and coordinate all aspects of survey preparation, manage survey processes, and ensure diligent follow-up on findings.
Vulnerability Assessment & Reporting: Proactively assess standards compliance, identify potential vulnerabilities, and report findings to key stakeholders with clear actionable insights.
Training & Education: Develop and conduct targeted training programs for management, educators, and staff in response to identified or potential deficiencies, fostering a culture of compliance.
To be successful in this role you must have regulatory expertise, patient safety acumen and strong analytical/problem-solving skills.
Job Requirements
Required
Bachelor's degree in healthcare administration, nursing or other healthcare-related field.
Five years of progressively responsible related work experience that would demonstrate attainment of the requisite job knowledge.
Minimum of three (3) years of progressive management responsibility in an acute care setting, one (1) of which is related to managing an organization’s or department Quality, Safety, or Regulatory Program.
Minimum of two (2) years of clinical, patient experience or equivalent.
Experience developing, and implementing clinical, service and operation process initiatives, both small and large scale.
Or, any equivalent combination of education and experience which meets requirements and provides the required knowledge, skills and abilities to perform the essential functions of the position.
Preferred
Active Washington State Registered Nurse License
Certified Professional in Healthcare Quality (CPHQ)
About Dignity Health
Dignity Health is a health care provider that operates hospitals and clinics in California, Arizona, and Nevada. The company was founded in 1986 and is headquartered in San Francisco, California. Dignity Health provides a range of services, including emergency care, cancer care, and women's health. The company has over 60,000 employees and is committed to providing high-quality, affordable health care to its patients.
