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Manager of Patient Safety and Regulatory Readiness

Allegheny Health Network

  • Company AHN
  • Natrona Heights, PA - Allegheny Valley Hospital
  • Patient Support
  • Full time
  • Day (United States of America)

Company :

Allegheny Health Network

Job Description : 


The Manager of Patient Safety and Regulatory Readiness is responsible for the successful implementation of the AHN enterprise-wide patient safety and regulatory goals and objectives for the designated location.  Oversees the patient safety and regulatory functions Oversees regulatory and patient safety while working in tandem with the QSV division (including infection prevention, quality and pay for value) and the corporate departments (Risk Management, Legal, Privacy and Compliance).  Accountable for creating a culture of continuous regulatory readiness through proactive risk assessment and mitigation efforts while focusing on supporting a culture of safety.  Manage the policy administration infrastructure to support the formulation, review, approval and dissemination of policies and procedures.  


  • Perform management responsibilities to include, but are not limited to: involved in hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity.  Plan, organize, staff, direct and control the day-to-day operations of the department; develop and implement policies and programs as necessary; may have budgetary responsibility and authority. (20%)
  • Implement safety programs with a focused effort on opportunities for improvement within the designated location/institute. Lead and/or facilitate multidisciplinary patient safety initiatives to include safety reporting, root cause analysis and development of improvement proposals, while achieving successful outcomes which minimize harm to patients and staff. (25%)
  • Manage all aspects of investigations, inspections and surveys conducted by regulatory and accrediting agencies; prepare for and facilitate regulatory visits and construction occupancies, oversight of the regulatory surveyors; respond to the deficiencies by ensuring appropriate corrective measures have been taken which eliminate the deficiency. (15%)
  • Conduct regular assessments through audits (formal and informal) mock tracers and mock surveys.  Respond to actual or potential noncompliance by ensuring appropriate corrective action is taken to successfully eliminate the risk of deficiency and continue to monitor for sustained compliance. (10%)
  • Create a culture of regulatory readiness through continual proactive measures.  Educate all levels of staff on regulatory requirements, regulations and standards in development.
  • Provides expertise in the use of tools to assess quality and safety risks and harm events. (10%)
  • Ensure the hospital policies and procedures are consistent with laws, regulations and standards; ensure compliance with hospital policies. (5%)
  • Reports safety events to required agencies, such as: Pennsylvania Patient Safety Reporting System, MedSun, CMS, The Joint Commission, as established within legal timeframes. (5%)
  • Other related duties.



  • Bachelor's degree in Healthcare, Regulatory, Compliance or related field OR 6 years of progressive and relevant experience in lieu of degree


  • Master's degree in Healthcare, Regulatory, Compliance or related field

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement : This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times.  In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy. 

Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, age, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, age, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability. 

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