Manager of Operations for Patient Safety and Regulatory Accreditation

General Description:

Under general direction, is responsible for operationalizing, coordinating, and facilitating OU Health's regulatory compliance with federal, state, and local laws. Follows-up on patient safety initiatives and creates a culture of safety in all OU Health areas from an operational lens.

Essential Responsibilities:

Responsibilities listed in this section are core to the position. Inability to perform these responsibilities with or without an accommodation may result in disqualification from the position.

• Collaborates with managers within the system regarding operational responsibilities.

• Tracks laws, rules, or regulation changes for the accreditation body that governs OU Health that could impact patient safety.

• Serves as system-level liaison for regulatory reviews/inspections; facilitates development of regulatory action plans and communications.

• Utilizes programs to add resources for leaders within the organization to increase compliance (PowerBI, TJC Tracer, Uptime Health, CMMS Rounding, Safety Solutions with PressGaney)

• Operates a Command Center during the time that a Regulatory Agency is at one of OU Health's locations.

• Monitors, tracks data, and evaluates locations for compliance related to the standards of governing bodies.

• Stays informed regarding new and revised regulatory standards; develops communication and action plans to ensure OU Health compliance.

• Attends OU Health system meetings for Regulatory Compliance to have a voice and provide effective communication in an educational manner.

• Administrator for OU Health Regulatory Compliance Systems.

• Collaborates with other managers in the organization on audit trends and provides resources in an appropriate manner to improve initiatives within OU Health patient care areas.

• Collaborates with other leaders on survey activities to ensure staff and physicians have been given the resources to help manage their survey responsibilities.

• Responsible for oversight, management, and communication of ongoing patient tracer activities.

• Operationalize and monitor the regulatory inbox including researching and responding to questions related to compliance needs.

• Manage the internal communication Regulatory Compliance page as a resource for staff and physicians to have regulatory resources available.

• Give educational classes on the system programs that are governed by the regulatory compliance team to help managers, directors, and staff be regulatory ready at all times for employee and patient safety.

• Operational responsibilities with other departments or committee meetings as regular attendees.

• Conducts annual performance reviews with staff and serves as a mentor as well as a leader.

• Creates and distributes patient safety initiative metrics and monitoring reports to leadership.

General Responsibilities:

• Performs other duties as assigned.

Minimum Qualifications:

Education: Bachelor's Degree required.

Experience: Five (5) years of healthcare, clinical, patient safety, regulatory, or risk management experience required. 3 years of progressive leadership experience required.

License(s)/Certification(s)/Registrations(s): None.

Knowledge, Skills, and Abilities:

• Expert knowledge of federal, state, and local regulatory compliance standards related to healthcare, including The Joint Commission.

• Expert knowledge of health information and hospital systems and processes.

• Excellent organizational skills.

• Expert written and verbal communications skills to include negotiation skills.

• Ability to analyze, assemble, prepare, and present data at all levels throughout the organization.

• Skill in establishing and maintaining effective working relationships across the continuum.

• Expert ability to prioritize workload and respond to variability based on organizational needs.

• Excellent computer skills to include Microsoft products.