Director Facility Regulatory Outcomes

FMOLHS•Baton Rouge, LA

About The Position

The Director of Facilities Regulatory Outcomes provides system-level leadership and oversight for regulatory compliance, policy development, and authority having jurisdiction (AHJ) coordination across FMOLHS hospitals, clinics, and support facilities. Reporting to the Vice President of Construction and Facility / Plant Operations, this role ensures markets maintain consistent compliance with Joint Commission, CMS, NFPA, OSHA, EPA, and state and local requirements related to environment of care (EOC), life safety, and utilities management. The Director develops and standardizes policies, processes, and procedures for inspection, testing, and maintenance (ITM) programs across all markets, including regulatory documentation, reporting accuracy, and readiness for AHJ inspections and surveys. As the system subject matter expert for facility regulatory performance, the Director guides market facility directors, coordinates with Safety and Quality departments, and promotes consistent, survey-ready outcomes across FMOLHS. The role connects system governance with operational execution to drive standardization, accountability, and proactive risk mitigation.

Requirements

Bachelor's degree required.
Seven years of experience in healthcare facilities operations regulatory outcomes.

Responsibilities

Develop, implement, and maintain system-wide policies and procedures for compliance with Joint Commission, CMS, NFPA, OSHA, EPA, and state and local AHJ requirements.
Monitor market adherence to established standards and update policies and procedures to reflect regulatory changes.
Coordinate with Legal, Safety, and Quality teams to support consistent interpretation and implementation of regulations.
Serve as the primary system liaison with external regulatory authorities, surveyors, and inspectors.
Ensure each market maintains current documentation and testing records required for AHJ reviews.
Oversee responses to survey findings and ensure system-level corrective action plans are developed, implemented, and verified.
Design and maintain the FMOLHS Facilities Regulatory Manual, establishing standards for ITM, documentation, reporting, and escalation.
Lead review and approval of policy changes affecting facilities, utilities, and life safety, and ensure uniform implementation and audit readiness across markets.
Develop a system-wide regulatory performance dashboard consolidating survey outcomes, inspection findings, and compliance metrics.
Ensure data integrity and timely reporting, analyze performance for system and executive review, and identify trends, risks, and improvement opportunities.
Provide ongoing education and competency development for market facility directors, safety officers, and maintenance teams.
Facilitate system-level training on Joint Commission standards, CMS Conditions of Participation, and NFPA requirements.
Support new facility onboarding and transitions with regulatory orientation and readiness guidance.
Lead mock surveys and internal audits to evaluate readiness and close performance gaps.
Promote proactive compliance and prevention, and collaborate with the Vice President and Senior Director of Facilities on continuous improvement in regulatory performance.