AVP of Facilities and Engineering

Job DescriptionJob Description

                                           Associate Vice President of Facilities and Engineering

                                                                                                                                

Position Summary  Under the direction of the Vice President of Facilities Management and Support Services, the AVP shall

                                 provide leadership of the Safety (Environment and Occupational) Department, Fire and Life Safety

                                 Department, and Engineering Department to deliver services and special projects to promote a safe,

                                 functional and supportive environment to patient care and other functions.

  Essential Functions, *   Develop Scope of Services for the departments, and create and implement performance

   Competencies, and      measures and analyses improvements for submission to the Board of Trustees.

              Professional *

           Requirements *   Collaborate with executive leadership and clinical leadership and department heads in the

                                      ongoing development and reviews of hospital’s mission and implementation of operations

                                      policies, procedures and initiatives.

                                  *   By appointment of the CEO/President, Serve as the Chairperson of the Environment of

                                      Care/Physical Environment Committee to carry out its missions.

                                  *   Conduct Intracycle Monitoring (ICM)/Focused Standard Assessment (FSA) with plan of

                                      correction for any insufficient compliance for submission to The Joint Commission and

                                      implement the accepted plan by the due date.

                                  *   Provide Plan of Correction to demonstrate Evidence of Standard Compliance for any TJC’ s

                                      full survey Accreditation activity.

                                  *   Develop, implement, and provide support to other departments in the development and

                                      implementation of, the Environment of Care’s Management Plans.

                                  *   Comply with TJC’s standard, CMS’s condition of participation, NYS Codes and Rules and

                                      Regulations as well as local codes, national codes and federal laws such as Life Safety Code,

                                      ADA requirements, OSHA’s laws, etc.

                                  *   Prepare and present reports on accreditation and regulatory compliance matters to hospital’s

                                       oversight committees, including: Medical Board, Quality Management and Patient Safety,

                                      Infection Control, Emergency Management, Radiation Safety, etc.

                                  *   Meet with surveyors during inspections, such as TJC full Tri-annual survey/CMS Condition of

                                      Participation, Laboratory and Pathology CAP survey, NYS Department of Health

                                      unannounced surveys and planned pre-occupancy inspections, etc.

                                  *   Develop and maintain current policies and procedures and other documentation for

                                      inspection by all bodies.

                                  *   Serve as the hospital’s safety officer in compliance with TJC standards and CMS’ Condition of

                                       Participation as well as requirements of NYSDOH and other bodies.

                                  *   By appointment of the CEO/President, act on his behalf to stop any immediate jeopardy or

                                      threat of serious harm, injury or impairment to the life, safety or health of patients, staff or

                                      visitors or any disruption of critical functions.

                                  *   Collaborate with clinical leadership, executive leadership and ancillary staff to review safety

                                      risks and take measures to ensure the safety of patients.

                                  *   Collaborate with leadership, executive leadership and ancillary staff to take measures relating

                                      to issues such as ligatures/self-harm in the Emergency Department and inpatient acute care

                                      settings, violence against staff, etc.

                                  *   Participate with the risk insurer (Zurich Insurance Group) on property risk and loss

                                      prevention evaluations for fire and associated perils for insurance purposes.

                                  *   Work closely with Risk Management and General Counsel to respond to attorney’s request

                                      for information regarding litigant’s claims of injuries.

                                  *   Conduct environmental tours of the facility with staffs from executive leadership, clinical

                                      leadership, etc. to identify safety hazards, review practices & compliance with standards &

                                      regulations as well as assess the hospital’s survey readiness state.

Review and analyze information from Employee Incident Reports, staff complaints and other

                                      submissions, conduct safety and security risk assessment and take pro-active or remediation

                                      steps to mitigate risks identified.

                                  *   Certify the Summary Incident Report of Injuries and Illnesses (OSHA’s Form 300A).

                                  *   Review complaints from staff and patients on indoor air quality and environmental comforts

                                      and occupational hazards and take necessary actions. Draft response to any OSHA’s inquiry.

                                  *   Oversee the planning, development, implementation and management of the Utility

                                      Systems Management Program, as required by The Joint Commission.

                                  *   Ensure the delivery of services, including utilities, electrical, generator emergency power,

                                      plumbing, air conditioning and heating, elevator services, etc., to support patient care and

                                      other activities.

                                  *   Plan, organize, direct, manage and evaluate the work and activities of non-unionize and

                                      unionized staff as well as outside vendors and contractors  in the operation, testing,

                                      inspection and maintenance of the physical plant, utilities and infrastructures.

                                  *   Ensure the evaluation of the performance of the services.

                                  *   Represent the hospital in project turn-over, close-out and system commissioning events.

                                  *   Develop recurring operating budget, capital budget and personnel budget requests; monitor

                                       operational and program performance against approved budgets. Establish cost-

                                      containment measures to reduce expenditures.

                                  *   Ensure the maintenance of required building and permits as well as certificates and licenses

                                      by staff.

                                  *   Develop Management Plan and ensure the proper management of water-based systems,

                                      including cooling tower, domestic (potable) water for the prevention of legionella and other

                                      pathogens.

                                  *   Ensure compliance with requirements ASHRAE, New York City, New York State, CDC, TJC,

                                      etc.

                                  *   Develop and establish manuals for Emergency Operating Procedures (EOPs) and Standard

                                      Operating Procedures (SOPs) to provide steps & guidelines for staff to follow in the

                                      operation, use and maintenance of building systems and equipment.

                                  *   Collaborate with Emergency Management to develop their EOP.

                                  *   Establish a Work Order System to improve work efficiency, enhance performance on work

                                      requests, improve customer (department’s) satisfaction and comply with reporting

                                      requirements of TJC.

                                  *   Oversee the planning, development, implementation and management of the Fire Safety

                                      Program, as required by The Joint Commission and incompliance with local Fire codes.

                                  *   Develop a Fire Plan and life safety programs; conduct fire safety training of staffs and

                                      licensed independent contractors (LIC).

                                  *   Ensure that fire safety drills are performed in accordance with the Fire Plan, Fire code and

                                      requirements of regulatory and accreditation bodies.

                                  *   Ensure that all fire and life safety systems and related equipment are fully functional and

                                      code compliant. Monitor and ensure that the documentation of all inspections, tests and

                                      maintenance activities are timely and proper, as prescribed by regulations.

                                  *   Serve as a subject matter expert on the Life Safety Code in matters of planning, design and

                                       construction.

                                  *   Develop Interim Life Safety Code policies and conduct Life safety Code assessments.

 

                                                                                                                                                                           

 

                                                                                                                                    

                                  *   Develop and implement interim life safety measures (ILSM) to compensate for any building

                                      deficiencies identified during the assessments or any potential risks that may occur during

                                      construction activities.

                                  *   Manage staff during construction activities on small renovation projects to ensure compliance

                                       with requirements on noise, vibration, air quality, infection control, utilities, etc.

                                  *   Provide subject matter expertise on NYS DOH’ article 28 projects and Certificate of Need

                                      applications re requirement of NYS CRR, LSC and FGI Guidelines for Design and Construction

                                       of Healthcare Facilities, ADA requirements, etc.

 

   Formal Education This position requires a minimum formal education of Master's Degree and a minimum of 5 years job-related

    and Job-Related experience.

             Experience Desired (not required) criteria include:  Clinical experience in hospital setting.  Good analytical skills. 

                                  Strong written and verbal skills.  Competency in using a computer and programs such as Excel, Word and

                                  PowerPoint.

 License, Cert. Required, Certified Professional in Patient Safety

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