System Director Facility Ops Regulatory Compliance

Inspired by faith. Driven by innovation. Powered by humankindness. CommonSpirit Health is building a healthier future for all through its integrated health services. As one of the nation’s largest nonprofit Catholic healthcare organizations, CommonSpirit Health delivers more than 20 million patient encounters annually through more than 2,300 clinics, care sites and 137 hospital-based locations, in addition to its home-based services and virtual care offerings. CommonSpirit has more than 157,000 employees, 45,000 nurses and 25,000 physicians and advanced practice providers across 24 states and contributes more than $4.2 billion annually in charity care, community benefits and unreimbursed government programs. Together with our patients, physicians, partners, and communities, we are creating a more just, equitable, and innovative healthcare delivery system.

The System Director of Compliance and Training is responsible for the strategic development, implementation, and management of comprehensive compliance and training programs across Facility Maintenance Operations (FM OPs), National Real Estate, National Programs and Planning, and Design and Construction. This role ensures adherence to regulatory requirements, industry best practices, and CommonSpirit Health policies. The Director will oversee the development and execution of Facility Maintenance Operations (FM OPs) and Program Quality Evaluation (PQE) programs, as well as identify, prioritize, manage, and assign technical training within the Learning Management System (LMS) to enhance the skills and knowledge of FM OPs, National Real Estate, National Programs and Planning, and Design and Construction personnel. This position has supervisory responsibilities for up to four Compliance and Training Specialists.

Regulatory Compliance Management:

Develop, implement, and maintain a comprehensive compliance program for Facility Maintenance Operations (FM OPs) across all CommonSpirit Health facilities.
Oversee the scheduling, execution, and documentation of Facility Maintenance Operations (FM OPs) to ensure compliance with regulatory requirements and CommonSpirit Health standards.
Develop and manage the Program Quality Evaluation (PQE) program, a scored inspection that assesses hospital performance in managing Elements of Performance within the Life Safety, Environment of Care, and Emergency Management chapters where FM OPs have direct responsibilities.
Analyze PQE results to identify areas for improvement and develop corrective action plans.
Monitor and track compliance metrics, providing regular reports to the System Vice President of Facility Maintenance Operations and other stakeholders.
Stay current with changes in regulatory requirements and industry best practices, updating compliance programs and procedures as needed.
Serve as a subject matter expert on compliance-related matters, providing guidance and support to FM OPs staff.
Conduct internal audits and risk assessments to identify potential compliance gaps and develop mitigation strategies.
Collaborate with other departments, such as Legal, Risk Management, and Quality, to ensure a coordinated approach to compliance.
Ensures compliance with TJC, State Health Departments, NFPA, EPA, DEP, ADA and local building codes and all other authorities having jurisdiction (AHJ). 

Training Management:

Identify and prioritize technical training needs for FM OPs, National Real Estate, National Programs and Planning, and Design and Construction personnel.
Develop or source technical training programs on a variety of topics, including equipment maintenance, safety procedures, regulatory compliance, and industry best practices.
Manage and assign all identified training within the Learning Management System (LMS), ensuring proper tracking and completion.
Utilize a variety of training methods, such as classroom instruction, online learning, hands-on training, and simulations.
Evaluate the effectiveness of training programs, making adjustments as needed to improve learning outcomes.
Maintain accurate training records within the LMS, tracking employee participation and completion of required training.
Stay current with new technologies and training methodologies, incorporating them into training programs as appropriate.
Collaborate with subject matter experts to develop and deliver specialized training programs.
Manage the training budget, ensuring that resources are used effectively.
Develop and maintain LMS training curriculum and content.

Bachelor's degree in engineering, facilities management, healthcare administration, or a related field required. Master's degree preferred.

Minimum of 7 years of experience in facilities management, compliance, or training, with at least 3 years in a leadership role.

Required Licensure and Certifications (Minimum of 2):

CHSP, CHM, CSSGB, NFPA CLSS-HC, HACP-CMS/PE/IC

Strong knowledge of regulatory requirements and industry best practices related to healthcare facilities management, including The Joint Commission, NFPA, CHIQ, CMS, DNV and OSHA.
Experience developing and implementing compliance programs and training programs.
Experience managing and utilizing Learning Management Systems (LMS).
Excellent communication, interpersonal, and presentation skills.

Strong analytical and problem-solving skills.
Ability to work independently and as part of a team.
Proficiency in Google Suite of products.