Vice President, Safety and Regulatory Affairs

Note:

The compensation range(s) in the table below represent the base salaries for all positions at a given grade across the health system. Typically, a new hire can expect a starting salary somewhere in the lower part of the range. Actual salaries may vary by position and will be determined based on the candidate's relevant experience. No employee will be paid below the minimum of the range.

Pay ranges are listed as hourly for non-exempt employees and based on assumed full time commitment for exempt employees.

Minimum - Midpoint - Maximum

$0.00 - $0.00 - $0.00

The Vice President of Safety and Regulatory Affairs is a senior executive responsible for leading the hospital’s enterprise-wide strategies in patient safety and regulatory compliance
. Reporting to the Chief Medical Officer (CMO), this role is critical in developing and sustaining a high-reliability culture that prioritizes the safety of patients, staff, and visitors. The VP oversees incident management, risk mitigation, policy development, and proactive strategies to reduce harm while supporting the hospital’s mission of delivering safe, high-quality, and patient-centered care. The VP of Safety and Regulatory Affairs also directs development and implementation of a system wide accreditation program to ensure continuous compliance with all federal and state regulatory standards (The Joint Commission, CMS, DPH, MA BORIM).

The position requires expert knowledge in federal, state and TJC standards and clinical and operational expertise to achieve and maintain a continuous state of readiness. This includes, but is not limited to, functioning as an expert resource and consultant to the organization, as a liaison between the organization and accreditation or regulatory bodies, and as a resource in continuous improvement activities.

• Direct and continuously improve the hospital’s Patient Safety Program
  , including serious safety event (SSE) identification, response, and follow-up.
• Facilitate Root Cause Analyses (RCAs) and Failure Mode and Effects Analyses (FMEAs), ensuring systemic improvements are implemented and sustained.
• Champion a Just Culture environment that promotes transparency, learning, and non-punitive reporting of errors.

• Partners with clinical risk management
  , to lead safety event investigation, risk assessment, and reduction strategies.
• Oversee internal event reporting systems, ensuring timely documentation, response, and risk mitigation.
• Serve as the primary liaison with legal counsel on claims, litigation, and potential liability exposure.

• Ensure organizational compliance with all regulatory standards related to patient safety and risk, including The Joint Commission (TJC),
  Centers for Medicare & Medicaid Services (CMS),
  OSHA
  , and state health departments
  .
• Lead survey readiness and response activities, including mock surveys, staff education, and policy alignment.
• Monitor and update internal policies and procedures to maintain alignment with evolving regulatory standards.

• Drive the hospital’s transformation into a High Reliability Organization (HRO) by leading cultural initiatives that embed safety as a core value.
• Engage physicians, nurses, and administrative staff in safety improvement efforts and accountability structures.
• Promote awareness and education across the organization through training, safety rounds, and communication campaigns.

• Analyze safety and risk data trends and translate insights into actionable strategies for improvement.
• Develop and present dashboards and reports for senior leadership, the Board Quality and Safety Committee, and regulatory bodies.
• Track key performance indicators (KPIs) such as hospital-acquired conditions (HACs), serious safety events (SSEs), patient complaints, and malpractice claims.

• Lead a multidisciplinary team including patient safety officers, risk managers, and event coordinators.
• Foster collaboration across departments including nursing, medical staff, quality, compliance, and operations.
• Support recruitment, development, and retention of high-performing team members within the safety and risk function.

• Oversees BH Diversion Management Program.

• Minimum of 10 years of healthcare experience, including 5+ years in a leadership role related to patient safety or risk management.
• Strong knowledge of hospital operations, clinical workflows, and safety science principles.
• Familiarity with regulatory standards from TJC, CMS, and other relevant agencies.

• Clinical licensure (e.g., RN, MD, DO) highly preferred.
• Certified Professional in Healthcare Risk Management (CPHRM), Certified Professional in Patient Safety (CPPS), or related credential.
• Demonstrated experience leading RCA, FMEA, and high-reliability initiatives.
• Excellent analytical,…