General Summary of Position
The Assistant Director of Regulatory Affairs is responsible for the coordination of continual survey readiness across the hospital. The position encompasses various roles (e.g., life safety, coordinator, educator, and facilitator) and requires eective interpersonal and organizational skills to motivate sta to embrace a continual state of accreditation/survey readiness. This position plans, promotes, maintains, coordinates and directs the Environment of Care (EOC), emergency Management (EM) and Life safety (LS) activities with oversight of these activities at MedStar Southern Maryland Hospital Center and interpret the Joint commission requirements and OSHA regulation which apply to EOC, EM and LS; identify and generate improvement opportunities and need for process changes to accommodate and facilitate the safety, security and comfort of patients. Ensures policies and procedures are monitored and updated to include regulatory changes.
Primary Duties and Responsibilities
1. Continuously advises the Department Leader regarding new TJC updates, CMS conditions of participation, Sentinel Event Alerts, and other regulatory changes.2. Serves as the designated liaison with TJC, CMS, and other Federal, State and County regulatory agencies for accreditation preparation and survey readiness including those related to Environment of Care, Life Safety and Emergency Management. Participates with internal and external tasks forces, committees, and agencies regarding emergency preparedness, including those at MSMHC, regional and State levels. Acts as the local liaison with local re department/Fire Marshall's Oce.3. Reviews, revises and maintains the Emergency Operations Plan annually. Collaborates with appropriate leadership on the grant process for emergency management funds. Implements necessary changes. Coordinates with the Directors of Plant Operations, Biomedical Engineering and Security in maintaining a safe defect free environment for the patients, employees, physicians, volunteers and others, by the timely identication and resolution of abnormal/questionable situations. Maintains current Master Index of all Safety Data Sheets (SDS).4. Works directly with the Hospital Education Department to design, develop, coordinate and implement hospital wide and site-specic training regarding the MSMHC Emergency Management Plans. Investigates researches and makes recommendations regarding best practices with respect to emergency preparedness. Supports the implementation and ongoing education, training of the hospital Incident Command System throughout the hospital. Has intervening authority assigned by the hospital President to immediately intervene in any unsafe or potentially hazardous situations thereby preventing the action or process causing the unsafe environment to continue.5. Orchestrates the execution of a minimum of four (4) Hospital wide emergency preparedness drills per year. one of which must include a coordinated response between local services and MSMHC. Performs all duties associated with responding to appropriate emergency/life safety situations as dened in the SMH Emergency Management/Preparedness Manual. Ensures hospital compliance with all OSHA regulations6. Directs implementation of the Life Safety Plan including inspection, testing and maintenance of re suppression, detection, and alarm systems. Conducts 30-day inspections of portable re extinguishers in the Hospital and patient service areas of the Professional Oce Building. Conducts re and emergency preparedness drills according to federal, state and county regulations, as well as, per Joint Commission standards.7. In collaboration with quality, prepares 11. Actively participates in performance improvement and risk management programs utilizing information to further enhance safety, life safety, emergency management and hazardous in the environment of care.12. Functions as the Safety Officer for MedStar Southern Maryland Hospital Center
Minimum Qualifications
Education- Bachelor's degree required
- Master's degree preferred
Experience- 3-4 years Regulatory compliance experience in a healthcare setting required
- 1-2 years TJC experience preferred
- 1-2 years Policy writing experience required
Licenses and Certifications- Certified Healthcare Safety Professional - CHSP within 2 years preferred
Knowledge, Skills, and Abilities- Knowledge of NFPA codes
- Knowledge of Project Management
- Ability to demonstrate ethical behavior that supports the hospital's mission, values and commitment to compliance with all federal, state and regulatory laws. Inspires trust and exhibits honesty and integrity within the scope of daily activities.
- Current knowledge of laws and regulations concerning hospital regulations, safety, life safety, hazardous materials and waste, emergency preparedness in healthcare and incorporate knowledge into practice
This position has a hiring range of $93,142 - $175,968