Interim Director Clinical Risk, Patient Safety & Regulatory Affairs

HARTZ Search
May 4, 2021
Southern US, United States
Job Type




Private Client is an Award-Winning Health System

HARTZ Search invites you to explore an exciting opportunity with one of our award-winning healthcare system partners for an interim assignment as the Interim Director Clinical Risk, Patient Safety & Regulatory for a minimum 180-day project in the southwest/southern US.

Our client is currently in the TJC window and would need assistance, immediately.

The Director Clinical Risk, Patient Safety & Regulatory Affairs is responsible for developing, establishing, and monitoring processes to support ongoing regulatory compliance and survey readiness for the health system. Additionally, the Director will oversee the patient safety and clinical risk programs to ensure they are coordinated with the overall regulatory readiness program throughout the network. The Director works collaboratively with internal and external stakeholders, continuously improving processes in order to improve regulatory compliance while using resources efficiently and effectively.

The role supports the Chief Quality Officer (CQO) and the Executive Director of Quality Operations and Implementation in the establishment of an integrated patient safety and proactive continuous survey readiness program at the health system utilizing high reliability organizing concepts.


  • Plans, implements, directs, evaluates, and documents a proactive continuous survey readiness program for the organization designed to reduce and eliminate the risk of injury to patients, visitors, and employees.
  • In collaboration with the CQO and the Executive Director of Quality Operations and Implementation, interfaces with the hospitals administration, General Counsel, legal personnel, medical staff, medical records, human resources, quality management, patient relations, as well as all clinical and non-clinical departments involved in the health care delivery system regarding continuous survey readiness activities, clinical risks, and patient safety.
  • Facilitates mock surveys through tracer activities and annual self-assessment activities through The Joint Commission.
  • Provides consistent regulatory updates and education as needed. Guides staff development methods and materials for deployment.
  • Establishes policies and procedures and identifies gaps in regulatory compliance.
  • Oversees the implementation and governance of a robust process improvement and action plan following serious safety events, root cause analysis, and risk mitigation efforts.
  • Manages patient grievance follow up as reported through accreditation agencies.
  • Oversees the clinical risk program to include an alignment with the enterprise risk program and mitigation strategies for sentinel and serious safety events.
  • Develops direct reports by defining roles/responsibilities and expectations, assigning and communicating performance and promoting professional growth and accountability. Assists team in communicating and aligning work priorities with the organizational vision, mission, values, and service standards.
  • Submits applications, license renewals, and regulatory communications in a timely manner.
  • Works collaboratively with divisional and system partners to foster an environment of learning and high reliability organizing. 

Education and experience:

  • Master’s degree in healthcare or business administration, nursing, public health or related field of study from an accredited college or university.
  • CPHQ, CPHRM, CPPS, or CJCP certification obtained within one year of employment.
  • Current RN licensure by the Board of Nurse Examiners for the State of Texas or proof of reciprocity of licensure between the State of Texas and another state. Must be maintained throughout employment.
  • 3 years of experience in healthcare accreditation/regulatory compliance and/or risk management.
  • 3 years of experience healthcare improvement initiatives or committees.
  • 5 years of healthcare clinical experience.
  • Electronic medical record (Epic experience preferred).



Qualified Interim Professionals, please submit:

  • Your current resume
  • Daily rate requirements
  • Start date availability

Consideration will not be given without these details. We will be in touch immediately upon receiving your information. Thank you - we look forward to partnering with you!

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