Director of Regulatory Compliance & Patient

Director Of Regulatory Compliance & Patient Experience – RN

Neuro Psychiatric Hospital of Indianapolis is seeking a Director of Regulatory Compliance & Patient Experience – RN to lead facility-based efforts in regulatory compliance, risk management, patient safety, and patient and family experience. This highly visible leadership role works collaboratively with hospital leadership, physicians, staff, patients, and families to identify and address risks, promote a culture of safety and accountability, and ensure ongoing regulatory readiness.

The Director uses clinical expertise and sound judgment to drive meaningful improvements in patient care, safety, and the overall patient experience.

Responsibilities include:

• Implement and maintain a comprehensive facility-wide risk management program in collaboration with the Corporate Director of Quality and Compliance.
• Identify, investigate, analyze, and trend actual and potential risks involving patients, employees, visitors, clinical care, and facility operations.
• Lead or coordinate investigations of significant incidents, adverse events, near misses, complaints, grievances, and other potential exposures; ensure timely escalation and follow-through.
• Promote a culture of safety and effective incident reporting; educate staff on risk identification, reporting, mitigation, and prevention.
• Collaborate with facility leadership and corporate resources to assess potential liability, legal exposure, reportability, and regulatory notification when significant events occur.
• Develop and maintain systems that support patient safety, proactive risk reduction, and continuous regulatory readiness.
• Conduct routine and targeted facility rounds, tracers, audits, and mock surveys to identify clinical, environmental, operational, and regulatory vulnerabilities before they become adverse events or findings.
• Use RN clinical judgment during rounding and event review to identify patient-safety and care-delivery concerns and promptly escalate nursing or medical issues to the appropriate clinical leader.
• Partner with the Director of Nursing on nursing-related risk and readiness issues without assuming operational authority for nursing services.
• Review complaints and grievances for patient-safety, regulatory, clinical, legal, and reputational exposure; coordinate timely service recovery and follow-through with patients and families.
• Maintain a highly visible and accessible presence for patients and families and conduct proactive rounding to identify concerns early and prevent avoidable escalation.
• Coordinate Root Cause Analyses and other structured reviews for specified events; develop corrective and preventive actions and monitor effectiveness.
• Lead or coordinate the facility Safety Committee and support QAPI activities using incident, complaint, grievance, survey, environmental, and other risk data.
• Maintain continuous survey readiness and serve as a key facility resource during state, federal, accreditation, complaint, validation, and follow-up surveys.
• Coordinate survey requests, documentation, communication, and follow-up activities in partnership with facility and corporate leadership.
• Assist in development of Plans of Correction and regulatory responses; track corrective actions, evidence of implementation, and sustained compliance through closure.
• Identify repeat deficiencies, recurring events, high-risk patterns, and ineffective corrective actions and escalate them to facility and corporate leadership.
• Monitor facility cleanliness, organization, environment of care, safety, and overall presentation; ensure identified issues are assigned, corrected, verified, and sustained.
• Serve as a resource for risk management, patient experience, performance improvement, policy/procedure…