Signature Healthcare is Southeastern Massachusetts’ premier local provider of quality, personalized medical services. We are comprised of the award-winning not-for-profit Signature Healthcare Brockton Hospital; Signature Medical Group (SMG), a multi-specialty physician group of more than 150 physicians practicing in 18 ambulatory locations. We believe our distinctive Signature Healthcare team approach is the way healthcare should be: medical professionals across many locations communicating and collaborating, taking advantage of technologies and resources to make a difference in the lives and health of our patients.

Position Summary:

Under the general supervision of the Vice President of Quality Resources, the Manager of Regulatory Compliance is responsible for overseeing organizational activities related to compliance with standards applied by The Joint Commission (TJC) and the Centers for Medicare and Medicaid Services (CMS). This role involves interpreting licensure, regulatory, and accrediting requirements, assessing the organization’s current compliance, and providing direct support and consultative services to meet accreditation and regulatory standards. The Manager develops and monitors action plans for continuous survey readiness and coordinates TJC compliance activities. Utilizing tracer methodology, the Manager organizes tracer activity across the organization to evaluate compliance with standards, identify areas for improvement and support the development and evaluation of organizational action plans.

The manager collaborates across a matrixed system with various department leaders to develop and implement strategies for mitigating compliance-related risks, thus ensuring effective risk management practices are in place. The Manager employs Failure Mode and Effects Analysis (FMEA) and other risk assessment methodology to identify potential failures in processes and procedures, assessing their impact and likelihood, and prioritizing risk mitigation efforts accordingly.

The role ensures that compliance activities and organizational policies promote and support health equity, addressing disparities in healthcare delivery and outcomes. Conducting detailed data analysis to identify trends, risks, and areas for improvement in regulatory compliance and patient safety, the Manager utilizes data to inform decision-making and develop actionable insights related to accreditation and payor contracts.

The Manager prepares and as needed, presents reports on compliance activities, trends, and outcomes to senior leadership and governing bodies, while also serving as the subject matter expert, consultant, and trainer on all compliance-related activities within the organization to promote and support a culture of regulatory compliance and patient and staff safety. The manager continuously seeks and introduces innovative methods and technologies for data analysis.

This position requires experience in healthcare compliance, regulatory affairs, or a related field, a strong understanding of TJC and CMS standards and requirements, proficiency in data analysis and interpretation, and significant involvement in risk management. Excellent communication and interpersonal skills, strong organizational and project management skills, and the ability to manage multiple priorities and deadlines are essential for this role.The ability to build strong relationships within and across teams is a must.

Location: 680 Centre Street, Brockton, MA

Department: Quality Resources

This is a full-time 40 hour/ week position

Responsibilities:

• Demonstrates respect and regard for the dignity of all patients, families, visitors, and fellow employees to ensure a professional, responsible, and courteous environment.

• Commits to recognize and respect cultural diversity for all customers (internal and external).

• Communicates effectively with internal and external customers with respect of differences in cultures, values, beliefs and ages, utilizing interpreters when needed.

• Maintain current knowledge of DPH (Department of Public Health), CMS, Joint Commission, and other regulatory standards and regulations. Participate in developing, implementing, and leading strategies to comply with identified standards and regulations.
• Incorporate process improvement techniques (PDCA, Lean) into regulatory compliance activities.
• Act as a champion for the organization’s Culture of Safety program.
• Lead and coordinate The Joint Commission Steering Committee.
• Coordinate The Joint Commission Tracer Team process, ensuring active participation of leadership and management.
• Facilitate Tracer Team feedback to appropriate individuals.
• Maintain The Joint Commission SigNet page and lead proactive risk assessments and risk mitigation initiatives.
• Coordinate all communications between TJC and SHBH, including the Electronic Application, Intra-Cycle Monitoring Profile, the annual TJC invoices, TJC Survey, TJC Complaints, and updates any SHBH changes.
• Continuously review TJC website for educational resources, FAQs (Frequently Asked Questions), and standard updates. Review TJC Perspectives and educate appropriate individuals regarding future changes.
• Maintain awareness of the CMS Conditions of Participation (COPs) to ensure SHBH compliance.
• Actively participate in designated hospital-wide committees as appropriate.
• Participate in outside professional organizations, committees, and functions as a hospital representative.
• Develop, implement, and maintain policies related to regulatory standards.
• In partnership with Quality leaders, help define and execute Quality program performance improvement strategies.
• Develop and implement quality improvement initiatives to enhance patient outcomes and satisfaction.
• Analyze clinical data to identify areas for improvement and monitor progress towards quality goals.
• Facilitate multidisciplinary teams to drive quality improvement projects and initiatives.
• Ensure compliance with regulatory standards and accreditation requirements related to quality and safety and support teams and individuals to do the same.
• Conduct root cause analyses and implement corrective actions to address identified issues.
• Collaborate with healthcare providers and staff to implement evidence-based practices and clinical guidelines.
• Lead quality improvement training and education sessions for healthcare professionals.
• Participate in performance measurement and reporting activities to track quality metrics and outcomes, especially within the Quality Resources and Infection Control Departments.
• Utilize Lean and other process improvement methodologies to streamline workflows and eliminate waste.
• In concern with other organizational efforts, engage patients and families in quality improvement efforts through feedback mechanisms and patient engagement strategies.
• Performs other duties as assigned

BASIC KNOWLEDGE/SKILLS/APTITUDE/EXPERIENCE:

• Ability to solve practical problems and deal with a variety of variables in situations where only limited standardization may exist.
• Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.
• Must be able to reasonably make appropriate judgment in communications and actions with patients, physicians, other associates, outside agencies, and vendors.
  • Excellent interpersonal, organizational, prioritization, critical thinking, problem-resolution, and program management skills.
  • Knowledge of federal and state regulations and standards, specifically The Joint Commission (TJC), DPH, and CMS Conditions of Participation.
  • Competency in research and investigation techniques with the ability to interpret data, prepare reports, and propose solutions to performance gaps and quality and safety issues.
  • Proficiency with word processing, spreadsheets, database software, and office products.
  • Ability to independently prioritize work projects and comply with established/required deadlines.
  • Willingness to understand DEI frameworks to bring best practice solutions to drive organizational strategy.

• • Exceptional human leadership capability – listening, being curious, and willingness to learn from others.
  • Effective change management skills to implement workplace programs grounded in the principles of Patient Safety, RBC (Relationship-based Care), and DE&I (Diversity Equity and Inclusion).
  • Excellent written and verbal communication skills to clearly articulate ideas and decisions to stakeholders.
  • Ability to work collaboratively with a wide array of colleagues and clients to integrate Patient Safety, RBC, and DE&I best practices into daily operations.
  • Demonstrated ability to manage conflict and advance relationships and conversations.
  • Effective project management, program administration, and organizational skills.
  • Strong analytical skills to gather, interpret, deliver information, and make decisions from data.
  • Ability to multi-task, manage multiple constituents and multiple deadlines.
  • Passion for learning and a mindset of continuous improvement.
  • Strong strategic thinking aptitude, management experience, and analytic orientation.
  • Expert-level knowledge of the healthcare environment, strategic planning, change, and project management.
  • Excellent interpersonal skills with the ability to navigate highly complex projects through a consensus-driven environment.
  • Excellent organizational and time management skills with the ability to prioritize projects in connection with strategic priorities.
  • Excellent written and oral communication skills with the ability to deliver presentations to a wide variety of audiences.
  • Ability to interact regularly and confidently with C-Suite executives.
  • Ability to convert project and stakeholder needs into meaningful frameworks and provide guidance to key stakeholders.
  • Ability to interact and influence organization-wide and work collaboratively across functions, levels, and departments toward shared objectives.
  • High level of comfort with ambiguous situations and ability to maintain flexibility and adaptability while focusing on goals and important deadlines.
  • Interest in and commitment to the mission of improving clinical access to high-quality cancer care for marginalized patient populations.

Education/Experience/Licenses/Technical/Other:

1. Education: Advanced degree in a related field (e.g., healthcare administration, public health, business) or commensurate experience required.
2. Experience (Type & Length): Minimum of 3 years of experience in Risk Management and Patient Safety within a healthcare setting.Additional Infection Control experience preferred.
3. Certification/Licensure: Nursing or Physician Licensure preferred.
4. Software/Hardware:
5. Other: Office 365, ability to navigate electronic medical records, online regulatory portals and software applications.