Regulatory and Patient Safety Specialist Full Time 40 hours

The Regulatory and Patient Safety Specialist is responsible for the organization-wide coordination of regulatory compliance and patient safety efforts. This role supports and collaborates with the Director of Quality Patient Safety and Regulatory Affairs to ensure the hospital maintains continuous readiness with all regulatory bodies and advances its goals in quality safety and infection prevention. The Specialist serves as an educator advisor and coordinator across all levels of the organization building a culture of safety accountability and operational excellence. This position also partners with infection prevention surveillance and strategies to minimize healthcare-associated infections and aligns infection control programs with national standards.

Position Summary:

Under the guidance of the Regulatory and Risk Supervisor the Regulatory and Patient Safety Specialist is responsible for ensuring compliance with all regulatory requirements supporting accreditation readiness and leading components of the patient safety program. This individual develops surveillance systems facilitates risk mitigation strategies and leads improvement initiatives across clinical and non-clinical areas. The position collaborates with infection prevention staff department leaders employee health and facilities to ensure a safe environment for patients visitors and staff.

Position Responsibilities:

Regulatory Compliance

• Coordinates the organizations ongoing compliance with Joint Commission CMS and DPH standards.
• Organizes and supports the triennial and biannual accreditation surveys and other regulatory site visits.
  • Leads the annual TJC Periodic Performance Review (PPR) process.
  • Assists with applications deadlines and post-survey corrective action plans.
• Serves as a liaison to regulatory agencies.
  Maintains current knowledge of evolving standards and communicates updates to leadership and staff.
• Facilitates tracer activities and prepares survey readiness materials policies and staff education.
• Provides onboarding and annual regulatory training (e.g. HealthStream) including education for new hires.
  

Ongoing Regulatory Readiness

• Maintains and implements the unannounced survey readiness plan
• Coordinates preparation committees meeting agendas and follow-up documentation.
• Notifies leadership of changes in standards and organizes appropriate training
• Updates regulatory pocket guides and participates in department-specific regulatory drills and audits.
  

Accreditation Support

• Maintains records and summaries of organizational accreditations.
• Assists departments in preparation for accreditation cycles documentation review and mock surveys.
  

Patient Safety

• Supports Safety Starts with Me and other hospital-wide safety initiatives
• Participates in safety training curriculum delivery and culture of safety coaching.
• Partners with clinical and operational leadership to embed safety habits in daily work.
• Uses data to evaluate risks prioritize interventions and improve safety outcomes.
  

Infection Prevention and Control

• Collaborates closely with the Infection Prevention Specialist to support infection surveillance data analysis and prevention strategies across the organization.
• Assists in the development implementation and evaluation of infection prevention initiatives to reduce the risk of healthcare-associated infections (HAIs).
• Participates in the collection validation and reporting of infection-related data to the CDCs National Healthcare Safety Network (NHSN) including metrics such as MDROs CLABSIs CAUTIs SSIs C. difficile and VAEs.
• Contributes to policy and procedure development related to infection prevention in alignment with CDC guidelines CMS Conditions of Participation and The Joint Commission standards.
• Participates in or supports the Infection Prevention Committee and represents the organization in collaborative groups such as the CHA Infection Prevention Group.
• Engages in infection prevention rounding audits and tracer activities to identify opportunities for process improvement and risk mitigation.

Education

Bachelors Degree in Nursing Public Health Health Administration Microbiology or related field required. Masters Degree preferred.

Experience

Minimum of three (3) years in a healthcare setting with demonstrated experience in regulatory compliance patient safety infection prevention or quality improvement.

Licensure Certification Registration

• Current CT License consistent with training if applicable.
• Certification in Healthcare Quality (CPHQ) and/or Infection Prevention and Control (CIC) preferred; required within 2 years of hire.
  

Knowledge Skills and Ability Requirements

• Deep knowledge of federal and state healthcare regulations TJC standards and CMS Conditions of Participation.
• Strong written and verbal communication and facilitation skills.
• Ability to lead meetings projects and multidisciplinary initiatives.
• Demonstrated skills in planning delegating educating and problem-solving.
• Engages collaboratively with clinical and non-clinical teams across all organizational levels.
• Commitment to maintaining a safe compliant and patient-centered healthcare environment.
• Alignment with BHHCG CARE values and dedication to professional growth