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Director, Patient Safety And Regulatory Affairs

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Location: Fort Worth TX

Company Name: JPS Health Network

Occupational Category: 11-9199.00,Managers, All Other

Date Posted: 2020-03-18

Valid Through: 2020-04-17

Employment Type: FULL_TIME


Description: The Director Patient Safety & Regulatory Affairs is responsible for establishing and implementing processes to support ongoing compliance and survey readiness for all regulatory agencies. Additionally, the Director will oversee the patient safety and clinical risk programs to ensure they are coordinated with the overall regulatory readiness program through-out the network. The Director works collaboratively with internal and external stakeholders, continuously improving processes in order to improve regulatory compliance while using resources efficiently and effectively.

Typical Duties:
• Supports the Chief Quality Officer (CQO) in the establishment of an integrated patient safety and proactive continuous survey readiness program at JPS Health Network utilizing high reliability organizing concepts.
• Plans, implements, directs, evaluates, and documents a proactive continuous survey readiness program for the organization designed to reduce and eliminate the risk of injury to patients, visitors, and employees.
• In collaboration with the CQO, interfaces with the hospitals administration, General Counsel, legal personnel, medical staff, medical records, human resources, quality management, patient relations, as well as all clinical and non-clinical departments involved in the health care delivery system regarding continuous survey readiness activities, clinical risks, and patient safety.
• Facilitates mock surveys through tracer activities and annual self-assessment activities through The Joint Commission.
• Provides consistent regulatory updates and education as needed. Guides staff development methods and materials for deployment.
• Establishes policies and procedures and identifies gaps in regulatory compliance.
• Oversees the implementation and governance of a robust process improvement and action plan following serious safety events, root cause analysis, and risk mitigation efforts.
• Manages patient grievance follow up as reported through accreditation agencies.
• Oversees the clinical risk program to include an alignment with the enterprise risk program and mitigation strategies for sentinel and serious safety events.
• Provides direction and ongoing development for direct reports.
• Submits applications, license renewals, and regulatory communications in a timely manner.
• Works collaboratively with Patient Safety, Clinical Improvement, Clinical Risk, Outcomes Management, Organizational Effectiveness, and District Safety in order to foster an environment of learning and high reliability organizing.
• Performs other job related duties as assigned.

• Required Education and Experience:
• Masters Degree
• 4 years of experience in healthcare accreditation/regulatory compliance and/or risk management
• 4 years of experience healthcare improvement initiatives or committees.
• 10 years of healthcare clinical experience.
• Basic experience using Microsoft Professional Office Suite to include Word, Excel, PowerPoint and Outlook.
• CPHQ or CPPS certification obtained within one year of employment.
• Preferred Education and Experience:
• 3 plus years of experience in healthcare risk management in a large healthcare system.
• 5 plus years of experience in healthcare regulatory and accreditation in a large healthcare system.
• * Required Licensure/Certification/Specialized Training:
• Registered Nurse
• Current licensure by the Board of Nurse Examiners for the State of Texas or proof of reciprocity of licensure between the State of Texas and another state. Must be maintained throughout employment.
• Preferred Licensure/Certification/Specialized Training:
• Certified Professional in Healthcare Risk Management (CPHRM)
• Certified Professional in Healthcare Quality (CPHQ)
• Certified Joint Commission Professional (CJCP)
• Green Belt certification