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 organization’s 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