Manager, Regulatory and Quality (Columbia Gorge)

Adventist Health • The Dalles, OR

2d • Onsite

About The Position

Responsible for the day-to-day coordination, implementation, and monitoring of activities that support continuous accreditation readiness, regulatory compliance, and quality improvement within the hospital. Ensures that operational practices align with the requirements of the Centers for Medicare and Medicaid Services (CMS), The Joint Commission (TJC), state agencies, and other regulatory and accrediting bodies. Executes processes that sustain compliance with corrective action plans, prepare departments for surveys, and drive targeted performance improvement projects. This includes conducting tracers, audits, and readiness rounds; facilitating action plan development with department leaders; and coaching frontline staff to embed compliance and quality standards into everyday practice. In partnership with nursing, medical staff, and quality leaders, the Manager maintains and interprets measurement systems, dashboards, and quality indicators to track progress, identify gaps, and escalate risks. Contributes to initiatives that reduce patient harm, improve clinical effectiveness, and strengthen performance on external benchmarks such as CMS Star Ratings. Provides supervision, mentorship, and professional development to assigned staff, fostering a culture of accountability and continuous improvement. Supports survey logistics, regulatory documentation, and timely reporting, ensuring that the organization is consistently prepared for external review and positioned to achieve high-quality, safe, and compliant care delivery.

Requirements

• Bachelor's degree in nursing, business administration, hospital administration or equivalent combination of education/related experience: Required
• Three years' experience in accreditation or regulatory compliance and in quality, patient safety, or performance improvement: Required
• Clinical background: Required
• Lean or Six Sigma Green Belt or GE Change Management certification: Required within two years of hire

Nice To Haves

• Five years' experience in healthcare accreditation and regulatory affairs with a successful track record of effective accreditation and regulatory affairs activities and outcomes: Preferred
• Two years' leadership experience in regulatory, quality, patient safety, performance improvement, or healthcare administration: Preferred
• Lean or Six Sigma Green Belt (LGB) or PROSCI-CCMP: Required

Responsibilities

• Coordinate, implement, and monitor activities supporting continuous accreditation readiness, regulatory compliance, and quality improvement.
• Ensure operational practices align with CMS, TJC, state agencies, and other regulatory/accrediting bodies' requirements.
• Execute processes for corrective action plans, survey preparation, and performance improvement projects.
• Conduct tracers, audits, and readiness rounds.
• Facilitate action plan development with department leaders.
• Coach frontline staff on compliance and quality standards.
• Maintain and interpret measurement systems, dashboards, and quality indicators in partnership with leaders.
• Contribute to initiatives reducing patient harm and improving clinical effectiveness.
• Provide supervision, mentorship, and professional development to assigned staff.
• Support survey logistics, regulatory documentation, and timely reporting.
• Align regulatory compliance programs with organizational strategy, quality initiatives, patient safety priorities, and risk reduction goals.
• Develop, implement, monitor, and improve structures for high quality, safe, cost-effective healthcare.
• Assist managers and leaders in mobilizing teams for continuous accreditation standards compliance.
• Coordinate contract renewal and oversight activities for regulatory compliance monitoring systems.
• Provide leadership and expertise in achieving organizational goals for accreditation, licensing, and regulatory compliance.
• Manage a team to safeguard facility licensing, maintain accreditations/certifications, and assure compliance with healthcare regulations.
• Manage logistics, conduct mock surveys, and maintain communication regarding regulatory compliance changes.
• Conduct annual State regulatory compliance assessments.
• Develop and maintain action plans and responses to citations.
• Collect data, prepare graphic presentations, and compile reports to demonstrate compliance.
• Review, interpret, and assist departments, leadership, and Medical Staff with Federal, State, and Joint Commission standards and regulations.
• Manage daily operations of quality, patient safety, regulatory, and performance improvement programs.
• Supervise and develop Quality/PI, regulatory, and patient safety staff.
• Ensure alignment of local activities with system strategic priorities.
• Lead patient safety initiatives, including root cause analyses, proactive risk assessments, and corrective action follow-up.
• Manage site's event reporting and learning systems.
• Promote a culture of safety and just culture principles.
• Facilitate and oversee improvement projects to reduce harm, improve clinical outcomes, and enhance operational efficiency.
• Apply Lean, Six Sigma, and other performance improvement methodologies.
• Monitor project outcomes and ensure sustainability of improvements.
• Ensure timely collection, validation, and reporting of quality, safety, and regulatory metrics.
• Prepare and present data to entity leaders, committees, and boards.
• Partner with system Quality and regulatory team and Patient Safety on benchmarking and external reporting requirements.
• Provide training and mentorship on patient safety and quality improvement methods.
• Foster interdisciplinary collaboration.
• Perform other job-related duties as assigned.

Benefits

• All required vaccinations as a condition of employment and annually thereafter, where applicable. Medical and religious exemptions may apply.

What This Job Offers

• Job Type: Full-time
• Career Level: Manager