Regulatory Readiness Program Manager

Melrose/Wakefield Hospital, part of the Tufts Medicine system, has been offering the highest quality and accessible healthcare to the local community for over 130 years. With two hospital campuses, Level III Trauma Center, Level III Special Care Nursery, Breast Health Center, Cardiovascular Center and over 20 locations and 50 specialties, Melrose/Wakefield Hospital offers many opportunities to grow your career.

Job Overview

This position leads efforts to ensure continuous organizational compliance and ongoing survey readiness with clinical quality and patient safety standards and regulations required by The Joint Commission (TJC), Massachusetts Department of Public Health (DPH), Center for Medicare and Medicaid Services (CMS) and other regulatory agencies as needed. In this role, the Manager proactively plans, implements, and coordinates continuous improvement and readiness efforts related to regulatory surveys. Acts as a resource across the organization, overseeing complex projects to completion, facilitating teams engaged in regulatory readiness efforts, collaborating with leaders and staff, and is a role model and expert in team training, change management theory, and regulatory standards.This transformational leadership role focuses on the following:

• Continuous safety and quality improvement efforts and/or initiatives;

• Direct and collegial oversight and/or support specific to ongoing accreditation and regulatory requirements during and after the completion of on and off-site surveys;

• Subject matter expert in accreditation and regulatory requirements;

• Leads collaborative and collegial system wide rounding efforts to identify, recommend facilitate and support horizontally and vertically within the healthcare system to ensure continuous alignment with accreditation and regulatory requirements.

Minimum Qualifications

1. Bachelor's degree.

2. Three (3) years of experience in healthcare leadership, Regulatory, Quality, and Patient Safety.

Duties and Responsibilities

The duties and responsibilities listed below are intended to describe the general nature of work and are not intended to be an all-inclusive list. Other duties and responsibilities may be assigned.

1. Serves as the organizational expert for The Joint Commission, DPH and CMS standards, regulations, and Conditions of Participation (CoPs).

2. Responsible for the interpretation and communication of regulatory requirements throughout the organization.

3. Provides education and consultation to administrative and clinical leadership, staff and faculty regarding the requirements of accreditation and regulatory organizations, using both formal and informal venues, e.g. presentations, publications, email, computer-based methods.

4. Provides guidance and assistance to departments, sections, units, and programs regarding improvements needed to monitor and ensure compliance with regulations & standards for TJC, DPH and CMS.

5. Provides informal consultation and advice to assist administrative and clinical leaders and their departments in improving performance.

6. Facilitates development of tools, policies, procedures, and learning aids to promote compliance with standards.

7. Works closely with Patient Safety/Risk Management, Quality Improvement and Data Analytics including coordination of the Joint Commission Performance Improvement and NPSG standards compliance.

8. Leads a coordinated response to unannounced external accrediting or regulatory agency visits such as DPH, Joint Commission or CMS.

9. Works with Patient Safety/Risk Management on an as-need basis to support BORM and DPH requirements regarding reporting of adverse events.

10. Develops, coordinates, and implements all aspects of the annual continuous readiness plan.

11. Completes annual TJC application.

12. Supports response to agency requests for revision and corrective action plans.

About Melrose/Wakefield Hospital

Melrose/Wakefield Hospital and Lawrence Memorial Hospital of Medford are two campuses with one community in mind: the people of north suburban Boston. Melrose/Wakefield Hospital and Lawrence Memorial Hospital are distinguished by the range of high-quality clinical care and services. Our teams welcome everyone with hospitality and humanity. We focus on reducing health disparities through 40+ local health programs across a system of hospitals, urgent care locations, outpatient services, and community physicians.

Core to our values, Melrose/Wakefield Hospital's commitment to community is demonstrated by our many local health programs throughout our service area and participation in partnerships with community agencies and events, and education programs in more than 10 communities to support the wellness and health of our residents.

Tufts Medicine is a leading integrated health system bringing together the best of academic and community healthcare to deliver exceptional, connected and accessible care experiences to consumers across Massachusetts. Comprised of Tufts Medical Center, Lowell General Hospital, MelroseWakefield Hospital, Lawrence Memorial Hospital of Medford, Care at Home - an expansive home care network, and large integrated physician network. We are an equal opportunity employer and value diversity and inclusion at Tufts Medicine. Tufts Medicine does not discriminate on the basis of race, color, religion, sex, sexual orientation, age, disability, genetic information, veteran status, national origin, gender identity and/or expression, marital status or any other characteristic protected by federal, state or local law. We will ensure that individuals with disabilities are provided reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. Please contact us to request accommodation by emailing us at careers@tuftsmedicine.org.