Associate VP Facilities Regulatory Compliance & Teammate Education and

Job Summary 

Oversees Enterprise Facility regulatory compliance for fire & life safety requirements.  Identifies and disseminates best practices, leads technology solutions, and has responsibility for fire and life safety policies, procedures, and barrier management for the enterprise.  The AVP develops and implements systems that promote effective, efficient, and safe operations. Provides leadership, guidance, and direction in achieving outcomes consistent with the organization and service line mission, philosophy, goals, and objectives.  Responsible for developing programs, initiatives, training and education to support teammate development, skills training, and regulatory required training.   Additional responsibilities include planning, coordinating, and evaluating safety functions and strategies to assure a safe workplace, safe care and treatment for patients, and a safe facility for visitors.  Responsible for Facilities Division related inspections by all authorities having jurisdiction and coordinating responses to inquiries.

Essential Functions 

Regulatory Compliance – Leads all fire and life safety compliance in site operations, management plans, policies, procedures, and best practices, to include regulatory requirements for all Facilities teammate safety & training.  Lead for all enterprise property insurance fire & safety program management, surveys, and recommendations.  Works closely with and supports enterprise Quality & Accreditation, including performing general mock and targeted surveys.  Scope includes acute care hospitals, all other inpatient hospitals, ambulatory surgery centers, freestanding emergency departments, and all ambulatory-based patient services.  

 

• Responsible for scheduling, participating in and follow-up for general mock and targeted surveys, project design review, and code interpretation and guidance.
• Leads in developing action plans in response to compliance deficiencies.
• Develops and delivers life safety education, best practice, and training for all Facilities teammates.
• Responsible to develop programs and manage processes to assure complete, accurate and available barrier management plans for all managed facilities.
• Acts as the enterprise subject matter expert on life safety code compliance, offers guidance on code requirements, supports all regulatory and accreditation surveys and related activities.  
• Responsible for ensuring compliance with state guidelines for reporting adverse physical environment incidents. 
• Creates and manages compliance action plans for all CMS waivers and equivalencies.
• Oversight of fire alarm and suppression system Inspection, Testing, and Maintenance (ITM) program, contracting, and reporting. 

 

Facilities Teammate Safety & Training – Develops, manages and delivers programs to assure all Facilities teammates receive all required education and training, as well as other training identified by the Facilities service line. 

• Assists in investigating workplace injuries related to the physical environment across the enterprise.
• Ensure teammates compliance with required competencies.
• Oversight of Learning Management System.
• Develops and maintains teammate and leader onboarding tools and resources for service line. 

 

Facilities Teammate Development – Develops, manages and delivers programs for on-going teammate education and training, to include skills development, educational certificates, degree-eligible programs, and the Facilities Apprenticeship program across the enterprise. 

• Assist Facilities leadership with establishing succession planning.
• Assist with organizational established employee retention goals.

 

Additional responsibilities –

• Enterprise lead for site-based property insurance site visits, risk management action plans, and recommendations across the enterprise. 
• Coordinates closely with local, market, region and enterprise Quality, Accreditation, Emergency Management, Security, Facilities, Infection Prevention, Patient Safety, Purchasing, PDC, EVS, and other corporate services. 
• Assures consistency and appropriateness for all regulatory compliance-related policies and procedures.
• Develops and produces select KPIs, scorecards and information using analytics to support businesses practices, operational performance, and compliance.   
• Works cooperatively with all other facility-based and corporate departments, including OH&S, Infection Prevention, Project Design & Construction, Security, Environmental Services, Food & Nutrition Services, Accreditation, Clinical Engineering, and others as required.
• Collaborates with othe