The Lemuel Shattuck Hospital is seeking a dedicated Regulatory Readiness Coordinator to join our team under the direction of the Chief Quality Officer. In this critical role, you will lead efforts to ensure ongoing organizational compliance with quality and patient safety standards and regulations, as required by The Joint Commission, Center for Medicare and Medicaid Services (CMS), Department of Public Health (DPH), and other regulatory bodies. As the Regulatory Readiness Coordinator, you will develop, implement, and oversee regulatory readiness education, tracers, and standards assessments. You will actively support and participate in improvement activities aimed at enhancing the quality and safety of patient care. All personnel are expected to comply with hospital policies and applicable state and federal laws, including HIPAA and confidential peer review regulations.
Schedule: Monday - Friday 8:00AM-4:30PM
Duties and Responsibilities (these duties are a general summary and not all inclusive):
Develop, coordinate, and implement the hospital patient safety and continual readiness plans for TJC Accreditation and CMS Condition of Participation.Review incidents and compliance/risk calls; conduct risk investigations and root cause analyses.Oversee corrective action plans, patient complaints, and grievances to ensure regulatory compliance.Serve as the organizational expert on Joint Commission accreditation standards and CMS conditions of participation; support policy compliance.Interpret and communicate regulatory requirements, including hospital licensure and OSHA standards.Maintain effective relationships as the Joint Commission contact and provide guidance during surveys.Develop remedial action plans, monitor readiness progress, and report findings to appropriate committees.Chair the Regulatory Readiness Committee, ensuring ongoing compliance activities.Provide education and training for accreditation requirements in collaboration with the Education Leader.Lead or participate in performance improvement initiatives, including root cause analysis, proactive risk assessments, and methodologies like LEAN/Six Sigma.Required Qualifications:
Understand and apply healthcare principles, practices, and regulations.Utilize healthcare terminology and standard abbreviations.Prepare charts, graphs, and tables using standard methods.Comply with clinical policies, procedures, methods, and techniques.Conduct interviews and apply problem-solving techniques.Provide clear and concise written and oral instructions.Gather and analyze information through observation, questioning, and examination of records.Establish and maintain harmonious working relationships and participate in a multi-disciplinary healthcare team.Maintain confidentiality of patient information.Analyze medical data, draw conclusions, and make recommendations.Plan and conduct training or instruction in nursing using effective methods and techniques.Preferred Qualifications:
Understand the laws, rules, regulations, policies, procedures, specifications, standards, and guidelines governing agency and assigned unit activities.Explain the laws, rules, regulations, policies, procedures, specifications, standards, and guidelines.Evaluate nursing practices using standard methods.Apply the principles and practices of healthcare administration.About the Lemuel Shattuck Hospital:
Lemuel Shattuck Hospital is a fully Joint Commission accredited teaching facility that provides acute, subacute, and ambulatory care to patients referred by public agencies and private sector providers. Shattuck Hospital’s services help economically and socially disadvantaged patients to get high quality, cost-effective care from a staff that respects their dignity.
Located in the heart of Boston’s Jamaica Plain neighborhood, the Shattuck Hospital includes 248 inpatient beds including 95 Psychiatric beds and 29 Correctional Health beds. In addition, the Shattuck has a full outpatient clinic with many specialties that offers treatment to patients of the Department of Mental Health as well as Department of Correction and House of Correction inmates and community patients.
The Shattuck hospital is on the forefront of substance use disorder treatment including a Suboxone clinic serving 200 patients. In addition to direct medical services LSH hosts and supports an array of services located on the campus, serving patients struggling with addictions and homelessness.
Learn more about: what it’s like to work as a DPH nurse
Learn more about Shattuck Hospital: https://www.mass.gov/locations/lemuel-shattuck-hospital
Relocation information: https://www.mass.gov/service-details/dph-renovation-for-shattuck-hospital-replacement-building
Pre-Hire Process:
A criminal background check will be completed on the recommended candidate as required by the regulations set forth by the Executive Office of Health and Human Services prior to the candidate being hired. For more information, please visithttp://www.mass.gov/hhs/cori
Education, licensure, and certifications will be verified in accordance with the Human Resources Division’s Hiring Guidelines.
Education and license/certification information provided by the selected candidate(s) is subject to the Massachusetts Public Records Law and may be published on the Commonwealth’s website,http://www.mass.gov
If you require assistance with the application/interview process and would like to request an ADA accommodation, please click on the link and complete theReasonable Accommodation Online Request Form
For questions regarding this requisition, please contact Executive Office of Health and Human Services, Human Resources at 1-800- 510-4122 Ext. #4
The Lemuel Shattuck Hospital is seeking a dedicated Regulatory Readiness Coordinator to join our team under the direction of the Chief Quality Officer. In this critical role, you will lead efforts to ensure ongoing organizational compliance with quality and patient safety standards and regulations, as required by The Joint Commission, Center for Medicare and Medicaid Services (CMS), Department of Public Health (DPH), and other regulatory bodies. As the Regulatory Readiness Coordinator, you will develop, implement, and oversee regulatory readiness education, tracers, and standards assessments. You will actively support and participate in improvement activities aimed at enhancing the quality and safety of patient care. All personnel are expected to comply with hospital policies and applicable state and federal laws, including HIPAA and confidential peer review regulations.
Schedule: Monday - Friday 8:00AM-4:30PM
Duties and Responsibilities (these duties are a general summary and not all inclusive):
Develop, coordinate, and implement the hospital patient safety and continual readiness plans for TJC Accreditation and CMS Condition of Participation.Review incidents and compliance/risk calls; conduct risk investigations and root cause analyses.Oversee corrective action plans, patient complaints, and grievances to ensure regulatory compliance.Serve as the organizational expert on Joint Commission accreditation standards and CMS conditions of participation; support policy compliance.Interpret and communicate regulatory requirements, including hospital licensure and OSHA standards.Maintain effective relationships as the Joint Commission contact and provide guidance during surveys.Develop remedial action plans, monitor readiness progress, and report findings to appropriate committees.Chair the Regulatory Readiness Committee, ensuring ongoing compliance activities.Provide education and training for accreditation requirements in collaboration with the Education Leader.Lead or participate in performance improvement initiatives, including root cause analysis, proactive risk assessments, and methodologies like LEAN/Six Sigma.Required Qualifications:
Understand and apply healthcare principles, practices, and regulations.Utilize healthcare terminology and standard abbreviations.Prepare charts, graphs, and tables using standard methods.Comply with clinical policies, procedures, methods, and techniques.Conduct interviews and apply problem-solving techniques.Provide clear and concise written and oral instructions.Gather and analyze information through observation, questioning, and examination of records.Establish and maintain harmonious working relationships and participate in a multi-disciplinary healthcare team.Maintain confidentiality of patient information.Analyze medical data, draw conclusions, and make recommendations.Plan and conduct training or instruction in nursing using effective methods and techniques.Preferred Qualifications:
Understand the laws, rules, regulations, policies, procedures, specifications, standards, and guidelines governing agency and assigned unit activities.Explain the laws, rules, regulations, policies, procedures, specifications, standards, and guidelines.Evaluate nursing practices using standard methods.Apply the principles and practices of healthcare administration.About the Lemuel Shattuck Hospital:
Lemuel Shattuck Hospital is a fully Joint Commission accredited teaching facility that provides acute, subacute, and ambulatory care to patients referred by public agencies and private sector providers. Shattuck Hospital’s services help economically and socially disadvantaged patients to get high quality, cost-effective care from a staff that respects their dignity.
Located in the heart of Boston’s Jamaica Plain neighborhood, the Shattuck Hospital includes 248 inpatient beds including 95 Psychiatric beds and 29 Correctional Health beds. In addition, the Shattuck has a full outpatient clinic with many specialties that offers treatment to patients of the Department of Mental Health as well as Department of Correction and House of Correction inmates and community patients.
The Shattuck hospital is on the forefront of substance use disorder treatment including a Suboxone clinic serving 200 patients. In addition to direct medical services LSH hosts and supports an array of services located on the campus, serving patients struggling with addictions and homelessness.
Learn more about: what it’s like to work as a DPH nurse
Learn more about Shattuck Hospital: https://www.mass.gov/locations/lemuel-shattuck-hospital
Relocation information: https://www.mass.gov/service-details/dph-renovation-for-shattuck-hospital-replacement-building
Pre-Hire Process:
A criminal background check will be completed on the recommended candidate as required by the regulations set forth by the Executive Office of Health and Human Services prior to the candidate being hired. For more information, please visithttp://www.mass.gov/hhs/cori
Education, licensure, and certifications will be verified in accordance with the Human Resources Division’s Hiring Guidelines.
Education and license/certification information provided by the selected candidate(s) is subject to the Massachusetts Public Records Law and may be published on the Commonwealth’s website,http://www.mass.gov
If you require assistance with the application/interview process and would like to request an ADA accommodation, please click on the link and complete theReasonable Accommodation Online Request Form
For questions regarding this requisition, please contact Executive Office of Health and Human Services, Human Resources at 1-800- 510-4122 Ext. #4
First consideration will be given to those applicants that apply within the first 14 days.
MINIMUM ENTRANCE REQUIREMENTS:
Applicants must have at least (A) three years of full-time, or equivalent part-time, experience as a registered nurse in a recognized hospital, clinic or medical facility and (B) of which at least two years must have been in a supervisory, administrative, or managerial capacity, or (C) any equivalent combination of the required experience and the substitutions below.
Substitutions:
I. A Graduate degree with a major in Nursing may be substituted for a maximum of one year of the required (A) experience. No substitutions will be allowed for the required (B) experience.
Education toward such a degree will be prorated on the basis of the proportion of the requirements actually completed.
SPECIAL REQUIREMENTS FOR ALL LEVELS IN SERIES: Current and valid registration as a professional nurse under the Massachusetts Board of Registration in Nursing .
Recent graduates from an approved school of nursing must have applied for the first available registered nurse examination.
Special Requirements: Based on assignment, possession of a current and valid Massachusetts Motor Vehicle Operator's license may be required.
Salary placement is determined by a combination of factors, including the candidate’s years of directly related experience and education, and alignment with our internal compensation structure as set forth by the Human Resources Division’s Hiring Guidelines. For all bargaining unit positions (non-management), compensation is subject to the salary provisions outlined in the applicable collective bargaining agreement and will apply to placement within the appropriate salary range
Comprehensive Benefits
When you embark on a career with the Commonwealth, you are offered an outstanding suite of employee benefits that add to the overall value of your compensation package. We take pride in providing a work experience that supports you, your loved ones, and your future.
Want the specifics?Explore our Employee Benefits and Rewards
Title 101 CMR 23.00 (“Regulation”) requires certain agency staff to have received the COVID-19 vaccination and Influenza vaccination, or have taken required mitigation measures, to prevent viral infection and transmission in State Hospitals and State Congregate Care Facilities. The Regulation applies to this position. Successful candidates will be required to acknowledge and attest to your vaccination status for both COVID-19 and Influenza
An Equal Opportunity / Affirmative Action Employer.Females, minorities, veterans, and persons with disabilities are strongly encouraged to apply.
The Commonwealth is an Equal Opportunity Employer and does not discriminate on the basis of race, religion, color, sex, gender identity or expression, sexual orientation, age, disability, national origin, veteran status, or any other basis covered by appropriate law. Research suggests that qualified women, Black, Indigenous, and Persons of Color (BIPOC)may self-select out of opportunities if they don't meet 100% of the job requirements. We encourage individuals who believe they have the skills necessary to thrive to apply for this role.
First consideration will be given to those applicants that apply within the first 14 days.
MINIMUM ENTRANCE REQUIREMENTS:
Applicants must have at least (A) three years of full-time, or equivalent part-time, experience as a registered nurse in a recognized hospital, clinic or medical facility and (B) of which at least two years must have been in a supervisory, administrative, or managerial capacity, or (C) any equivalent combination of the required experience and the substitutions below.
Substitutions:
I. A Graduate degree with a major in Nursing may be substituted for a maximum of one year of the required (A) experience. No substitutions will be allowed for the required (B) experience.
Education toward such a degree will be prorated on the basis of the proportion of the requirements actually completed.
SPECIAL REQUIREMENTS FOR ALL LEVELS IN SERIES: Current and valid registration as a professional nurse under the Massachusetts Board of Registration in Nursing .
Recent graduates from an approved school of nursing must have applied for the first available registered nurse examination.
Special Requirements: Based on assignment, possession of a current and valid Massachusetts Motor Vehicle Operator's license may be required.
Salary placement is determined by a combination of factors, including the candidate’s years of directly related experience and education, and alignment with our internal compensation structure as set forth by the Human Resources Division’s Hiring Guidelines. For all bargaining unit positions (non-management), compensation is subject to the salary provisions outlined in the applicable collective bargaining agreement and will apply to placement within the appropriate salary range
Comprehensive Benefits
When you embark on a career with the Commonwealth, you are offered an outstanding suite of employee benefits that add to the overall value of your compensation package. We take pride in providing a work experience that supports you, your loved ones, and your future.
Want the specifics?Explore our Employee Benefits and Rewards
Title 101 CMR 23.00 (“Regulation”) requires certain agency staff to have received the COVID-19 vaccination and Influenza vaccination, or have taken required mitigation measures, to prevent viral infection and transmission in State Hospitals and State Congregate Care Facilities. The Regulation applies to this position. Successful candidates will be required to acknowledge and attest to your vaccination status for both COVID-19 and Influenza
An Equal Opportunity / Affirmative Action Employer.Females, minorities, veterans, and persons with disabilities are strongly encouraged to apply.
The Commonwealth is an Equal Opportunity Employer and does not discriminate on the basis of race, religion, color, sex, gender identity or expression, sexual orientation, age, disability, national origin, veteran status, or any other basis covered by appropriate law. Research suggests that qualified women, Black, Indigenous, and Persons of Color (BIPOC)may self-select out of opportunities if they don't meet 100% of the job requirements. We encourage individuals who believe they have the skills necessary to thrive to apply for this role.