Regulatory Operations Program Manager

#REF!•Arlington, TX

16d•Hybrid

About The Position

Regulatory Operations Program Manager Bring your passion to Texas Health so we are Better + Together Work Location\: Texas Health Corporate, 612 E. Lamar Blvd., Arlington, TX 76011 Work Hours\: Full Time Days (8\:00am-5\:00pm) for 40 hrs/week (remote work allowed at manager's discretion) Department Highlights: Gain a sense of accomplishment by contributing to a teamwork environment. Receive excellent mentorship, comprehensive training, and dedicated leadership resources. Serve as a subject matter expert, providing guidance and support to staff and leadership across the hospital system. Hybrid Position What You Will Do\: I. Regulatory & Accreditation 1. Accesses/interprets/explains applicable regulations and standards; communicates the impact and criticality of applicable regulations and standards, including the added benefit to quality, safety and cost-effectiveness based on evidence-based practices. Use clinical knowledge and expertise to observe patient care, review documentation in the medical record, and evaluate compliance. 2. Conducts regulatory site visits with a focus on clinical aspects of regulatory and accreditation, based on annual and periodic risk assessments, to ensure compliance with TJC and CMS standards and regulatory requirements. 3. Conducts Tracer Inter-Rater Reliability exercises to validate continuous readiness assessments of regulatory/accreditation compliance. 4. Provides informal and formal regulatory/accreditation training to stakeholders as needs are identified. Assists with medical record reviews to identify gaps. 5. Reviews system/hospital policies and system order sets to ensure they adhere to regulatory/accreditation requirements. 6. Participates in healthcare mock survey activities in order to assess ongoing compliance with regulatory/accreditation requirements. 7. Provides support to hospitals/healthcare settings during official regulatory/accreditation surveys and visits 8. Identifies and communicates regulatory updates 50% II. Professional Engagement 1. Pursues/achieves/maintains required applicable certification and licensure. 2. Pursues professional growth and development of required knowledge and skills. a. Establishes at least one professional goal per year. b. Participates in at least five Regulatory-related educational opportunities per year. 3. Participates in a Regulatory-related professional organization. 4. Serves as subject matter expert for TJC/CMS/TAC regulatory operations. 10% III. Leadership & Integration 1. Utilizes the principles of influence, leadership, and change management to advance program goals and ensure changes are vetted by all stakeholder groups. 2. Utilizes skills in communication, relationship-building, and facilitation to ensure that all stakeholders feel accountable for continuous regulatory compliance. 3. Contributes to the development of other stakeholders through education and mentorship. 10% IV. Performance & Process Improvement 1. Identifies opportunities for improvement and continuously looks for ways to improve system processes and reduce harm using the principles of High Reliability. 2. Conducts and develops comprehensive risk assessments, prioritizes potential risks, and recommends evidence-based strategies for risk reduction. 3. Uses PI methodology to assess performance, sets achievable goals, uses data to initiate changes, and develops measures that will ensure sustainability of the improvement. 4. Annual analysis of system tracer program, development of system clinical and behavioral health tracers, implementation, and monitoring of results. 10% V. Data & Analytics 1. Leverages electronic systems to input, analyze, extract, and manage data to support and drive data integrity, streamline process, innovate practices, and achieve positive outcomes. 2. Creates meaningful electronic reports to enhance clinical regulatory and accreditation initiatives and guide strategy discussions with key stakeholders. 3. Conducts analysis of compliance and provides reports to identified owners and/or key stakeholders. 4. Assists with development of sustainable corrective actions. 10% VI. Patient Safety 1. Promote a safety culture and infrastructure that aligns with THR strategic objectives and meets regulatory/accreditation standards. 2. Identify active and inactive conditions within the hospital/healthcare setting that could contribute to stakeholder harm. 3. Prioritize high risk findings in order to escalate opportunities for improvement for system leadership awareness and support of risk mitigation strategies. 10%

Requirements

Bachelor's Degree Healthcare Req
5 Years Hospital setting/healthcare environment Req
RN - Registered Nurse Upon Hire Req
Or Other Clinical Licensure Upon Hire Req
Knowledge of performance improvement techniques, i.e. Lean, Six Sigma, PDSA and Reliability theory.
Excellent verbal and written communication, negotiation, and collaboration skills; ability to collect, analyze, and organize data; team facilitation skills; knowledge of regulatory and accreditation requirements, ability to educate and motivate others, ability to use Microsoft office applications.

Nice To Haves

Master's Degree Healthcare/Business Pref
1 Year Regulatory compliance and accreditation or quality improvement Pref

Responsibilities

Accesses/interprets/explains applicable regulations and standards
Conducts regulatory site visits
Conducts Tracer Inter-Rater Reliability exercises
Provides informal and formal regulatory/accreditation training to stakeholders
Reviews system/hospital policies and system order sets
Participates in healthcare mock survey activities
Provides support to hospitals/healthcare settings during official regulatory/accreditation surveys and visits
Identifies and communicates regulatory updates
Pursues/achieves/maintains required applicable certification and licensure
Pursues professional growth and development of required knowledge and skills
Participates in a Regulatory-related professional organization
Serves as subject matter expert for TJC/CMS/TAC regulatory operations
Utilizes the principles of influence, leadership, and change management to advance program goals
Utilizes skills in communication, relationship-building, and facilitation
Contributes to the development of other stakeholders through education and mentorship
Identifies opportunities for improvement
Conducts and develops comprehensive risk assessments
Uses PI methodology to assess performance
Annual analysis of system tracer program
Leverages electronic systems to input, analyze, extract, and manage data
Creates meaningful electronic reports
Conducts analysis of compliance and provides reports
Assists with development of sustainable corrective actions
Promote a safety culture and infrastructure
Identify active and inactive conditions within the hospital/healthcare setting that could contribute to stakeholder harm
Prioritize high risk findings