Manager Regulatory Safety

Job DescriptionThe Manager of the Regulatory, Safety and Infection Prevention will have the responsibility to oversee Regulatory activities and internal/external reporting requirements, planning, implementing and evaluating the infection prevention control program in accordance with regulatory, accreditation and evidence-based standards. This employee is responsible for analyzing and evaluating standards that relate to accreditation/certification and compliance with local, state, and federal regulations. Additionally, activities that support compliance management and educational development to ensure that staff have the necessary tools that promote Everyday Excellence. Responsibilities1. Program Effectiveness- Directs and supports hospital departments, medical staff leaders and senior management to facilitate cross functional regulatory compliance efforts utilizing tracer/second generation tracers and SAFER technology, tools, and analysis.- Works independently and effectively with stakeholders at all levels to analyze the purpose of their requests and provide suggestions so that resulting outcome meets needs assessed.- Assists and consults with regard to staff development in the area of Regulatory compliance to address needs-based education.- Subject matter expert for Regulatory management, Infection prevention and control and Accreditation, Certification, local, state in addition to federal rules and regulations- Plans and prepares an organizational survey plan to include survey calendar, pre-survey agendas, and pertinent workgroups and information to insure a smooth and successful survey outcome.- Serves on designated St. Francis committees as applicable.- Trains and mentor's direct reports2. Compliance and Regulatory Service:- Responsible for developing processes to support the reporting of pertinent information to stakeholders about regulatory compliance and areas of deficiency.- Consults in developing performance metrics that meet a Measure of Success for regulations that require Evidence of Standards compliance not limited to Plans of Correction- Ensures a timely review of policies and procedures that impact regulatory compliance.- Ensures adherence to the most current regulatory and accreditation trends/best practices by staying abreast through personal learning, job relevant seminars and workshops, attendance at professional conferences and affiliations with local, national and state organizations.- Prepares a variety of reports as requested by Regulatory and accrediting agencies.3. Safety program- Develop, implement and maintain the hospital-wide patient safety program - Lead incident reporting processes, ensuring timely review, analysis, and follow-up of safety events.- Conduct Root Cause Analyses (RCA), Failure Mode and Effects Analyses (FMEA), and other investigations to identify systemic causes and recommend corrective actions.- Oversee safety rounds, hazard surveillance, and environment-of-care inspections.- Coordinate safety education for staff, leaders, and physicians.- Manage the safety reporting tool, including user support, data analysis and trend reporting.- Ensure timely entry, review and closure of safety incidents.- Track and report performance metrics to leadership and safety committees.4. Infection prevention Manager - Develop, implement and monitor organizations infection prevention and control plan.- Lead surveillance activities for HAIs, including CLABSI, CAUTI, VAE, SSI, and MDROs.- Ensure compliance with CDC, OSHA, CMS and Joint Commission infection control standards.- Direct outbreak investigations, including root cause analysis and implementation of corrective actions. - Develop annual goals and staffing plans for the infection prevention program.5. Organizational Stewardship- Demonstrates selflessness by fostering a supportive and cooperative attitude with co-workers within the department and across the organization.- Meets all timelines for regulatory reporting - Maintain current knowledge of evolving regulations and best practices#CBQualificationsExperience3 years of applicable healthcare experience; Regulatory compliance experience preferred.Strong analytical and problem-solving skillsAbility to lead multidisciplinary teams Excellent written, verbal and presentation skills. Commitment to continuous improvementEducationBS in healthcare or BSN required; Master's degree preferred. For nursing, an active Louisiana Nursing licenseTrainingEvidence of training regarding standards such as CMS or Joint Commission complianceLicensureFor Nursing, Active Louisiana License