Manager of Regulatory Emergency Management

Job Description

_ SUMMARY:_

The Manager, Regulatory and Emergency Management is responsible for the leadership, coordination, and oversight
of La Rabida Children's Hospital's regulatory compliance, accreditation readiness, licensure management, and
emergency preparedness programs. Reporting to the COO, this position promotes continuous readiness for
accreditation and regulatory surveys, supports patient safety and high reliability initiatives, and directs the hospital's
comprehensive emergency management program.
The Manager serves as an organizational resource for regulatory standards, accreditation requirements, emergency
preparedness activities, and performance improvement initiatives. Working collaboratively with leaders, physicians,
employees, and external agencies, the position ensures ongoing compliance with regulatory and accreditation
requirements while strengthening organizational preparedness, resilience, and patient safety.

ESSENTIAL FUNCTIONS:

• Direct and oversee the hospital-wide regulatory compliance and accreditation readiness program.
• Ensure continuous compliance with The Joint Commission, CMS Conditions of Participation, Illinois Department of Public Health requirements, and other applicable regulatory standards.
• Lead planning, preparation, coordination, and follow-up activities for accreditation surveys, regulatory inspections, and validation reviews.
• Serve as the primary liaison for regulatory and accreditation agencies and coordinate organizational responses to survey findings.
• Oversee hospital licensure, certifications, permits, registrations, and required regulatory submissions.
• Monitor regulatory changes and communicate new requirements to organizational leaders and stakeholders.

• Conduct regulatory rounds, tracers, mock surveys, environmental tours, audits, and gap assessments to evaluate organizational compliance and readiness.
• Review policies, procedures, clinical documentation, and operational practices to identify regulatory vulnerabilities and opportunities for improvement.
• Develop corrective action plans and monitor implementation to ensure sustained compliance.
• Lead regulatory performance improvement initiatives utilizing evidence-based practices, risk reduction strategies, and High Reliability Organization principles.
• Analyze compliance findings, survey outcomes, and organizational data to identify trends, prioritize risks, and support leadership decision-making.
• Develop and maintain compliance dashboards, scorecards, reports, and readiness metrics.

• Develop, implement, and maintain the hospital's Emergency Management Program and Emergency Operations Plan (EOP).
• Ensure compliance with CMS Emergency Preparedness requirements, The Joint Commission standards, OSHA requirements, and applicable federal, state, and local regulations.
• Conduct annual Hazard Vulnerability Analyses (HVA) and risk assessments to identify threats and vulnerabilities and develop mitigation strategies.
• Develop and maintain emergency preparedness policies, procedures, and response plans.
• Coordinate emergency preparedness activities across all hospital departments to support organizational readiness and resilience.
• Manage emergency preparedness grants, programs, and reporting requirements as applicable.

• Plan, facilitate, and evaluate emergency preparedness training, tabletop exercises, functional exercises, and full-scale disaster drills.
• Educate staff regarding emergency response procedures, Hospital Incident Command System (HICS) roles, and individual responsibilities during emergencies.
• Maintain the Hospital Incident Command System structure and support activation, response, recovery, and after-action activities during emergency events.
• Serve as the primary liaison with healthcare coalitions, public health agencies, emergency management organizations, and community partners.
• Coordinate emergency communications, surge planning, resource management, and continuity of operations activities.
• Lead post-event evaluations, corrective action planning, and after-action reporting to strengthen future preparedness efforts.

• Participates in hospital committees, task forces, accreditation teams, and multidisciplinary work groups.
• Provides consultation and education to leaders and staff on regulatory compliance, accreditation standards, and emergency preparedness…