Chief Regulatory Officer - Johns Hopkins Hospital : Job Details

Position Summary

The Chief Regulatory Officer (CRO) is responsible for overseeing the enterprise-wide regulatory and accreditation operations. The Chief Regulatory Officer will oversee The Joint Commission (TJC), health department and Centers for Medicare and Medicaid Services (CMS) compliance for hospitals, behavioral health, opioid treatment, lab, point-of-care testing, rehabilitation, long term acute, ambulatory surgical centers, and home care accreditation, as well as disease-specific certifications. The CRO will oversee technical support, education for faculty and staff, policy review and revision for regulatory implications, and consultation in both preparation for and response to surveys.

The CRO will, in collaboration with designated physician leadership, develop recommendations for currently non-accredited patient care locations including Johns Hopkins Community Physicians and Johns Hopkins University Clinics and other entities at various locations. These entities may include, but are not limited to, outpatient pharmacies, clinical research, urgent care, and radiation oncology sites.

Role Accountabilities Include:

• Provides consultative mock surveys to prepare for external regulatory surveys
• Educates staff, leadership and providers on compliance with regulatory requirements
• Chair health system workgroups to harmonize/standardize strategies to assure regulatory compliance.
• Actively participate in departmental and/or system-wide committees, sharing expertise and representing regulatory point of view.
• Provides access to JHM resources for mitigation of mock survey findings
• Creates processes for coordination and effective health system resource allocation for regulatory compliance
• Develop standardized entity mock tracer team
• Builds infrastructure (tools, staff and resources) for best practices, identifying and responding to external regulatory mandates, sharing lessons learned at all JHM entities
• Drafts recommendations for JHM infrastructure to support regulatory compliance in the non-accredited JHU satellite sites
• Updates key JHHS management staff of regulatory changes, developments, and implications of new legislative initiatives. Coordinates those systems necessary for:

---- Regulatory compliance support at the entity level in preparing for surveys and responding to survey findings

---- Regulatory leadership for improved performance on surveys conducted by The Joint Commission (TJC), Department of Health and Mental Hygiene (DHMH), and Centers for Medicare and Medicaid Services (CMS)

---- Entity-specific customized and intensive reviews, audits, and mock surveys

---- Advanced efficiency of efforts in quality, patient safety, and regulatory compliance

---- Enhanced provider and staff education

---- Entity-specific policy & procedure review and recommendations

---- Risk reduction across the entities through strengthened regulatory compliance, sharing of best practices and lessons learned amongst JHM entities

Qualifications:

• Master's degree required. Master's Degree in Nursing or Allied Health is preferred.
• Certified Professional in Healthcare Quality (CPHQ) preferred
• Minimum of 10 years of related healthcare experience including 5-7 years of management experience in operational, administrative, or management required, preferably within an academic medical center.
• Requires an understanding of policies, procedures, regulations, standards, organizational structure, and information systems used in academic and community settings.
• Knowledge of health care business operations, design and management of EPIC, and project management processes.
• Knowledge of Federal and state regulatory guidelines and requirements and accrediting organizations' standards – TJC, CMS and MIEMSS, etc.