Regulatory Readiness Manager

Connecticut Children’s is the only health system in Connecticut that is 100% dedicated to children. Established on a legacy that spans more than 100 years, Connecticut Children’s offers personalized medical care in more than 30 pediatric specialties across Connecticut and in two other states. Our transformational growth establishes us as a destination for specialized medicine and enables us to reach more children in locations that are closer to home. Our breakthrough research, superior education and training, innovative community partnerships, and commitment to diversity, equity and inclusion provide a welcoming and inspiring environment for our patients, families and team members.

At Connecticut Children’s, treating children isn’t just our job – it’s our passion. As a leading children’s health system experiencing steady growth, we’re excited to expand our team with exceptional team members who share our vision of transforming children’s health and well-being as one team. 

The Regulatory Readiness Manager is responsible for coordinating, planning and organizing the overall 

regulatory readiness (e.g. CMS, DPH, TJC) of Connecticut Children’s. Recommends and implements 

improvements in key processes, policies and/or procedures as they relate to regulatory compliance. Works as an internal consultant with medical staff, nursing, support services, and other departments to plan, organize, facilitate, implement and measure efforts to improve process efficiencies, assess regulatory compliance and improve overall patient safety and clinical quality. This position reports to the Senior Vice President, Quality 

REGULATORY READINESS

In conjunction with Hospital Departments and Committees, works to gauge the readiness and compliance for internal 

and external surveys by DPH, TJC, CAP, OSHA, and others. Responsible for site visit preparation, coordination of site visit logistics and response, as well the coordination of report-out to management of major regulatory changes and issues and mock or real survey results. Ensures organizational readiness through, but not limited to the following:

• Coordinating and leading tracer rounds (mock surveys) to assess compliance with regulatory requirements and

helping to prioritize and remediate to improve performance.

• Developing and disseminating mock and real survey issues related to regulatory standards and hospital policy

compliance.

• Creating and developing strategic educational and training programs relating to compliance issues, safety and quality issues, and continuous regulatory readiness.
• Facilitating the coordination of multidisciplinary efforts in regard to regulatory readiness (e.g. PPR completion,

measurement of success data, DPH corrective action plans, and clinical charter teams with patient services).

CLINICAL SAFETY & QUALITY INITIATIVE SUPPORT

Collaborates with colleagues to support and coordinate clinical safety and quality activities throughout the institution 

and ensure that all safety and quality compliance issues are addressed and resolved in a timely manner. Collaborates with clinicians, Clinical Leaders, and members of key committees to set goals/assess Hospital performance, prioritize resources, implement change through facilitation and other activities, and assess project success. Related responsibilities include, but are not limited to the following:

• Providing leadership, guidance and facilitation to clinical and non-clinical departments. Serves on multiple hospital

committees to continually assess aspects of Hospital TJC/DPH/CMS readiness and compliance.

• Ensuring compliance with regulatory standards (TJC, CMS, DPH, etc.) for quality and safety reporting as relevant.
• Providing key regulatory safety and quality data highlighting business and operational issues requiring management

attention and resources. 

• Participating in department task forces and committees to provide operational input.

PROJECT MANAGEMENT

Responsible for independent action in project oversight, systems design and implementation, quality improvement and a variety of special projects. Uses Six Sigma, LEAN, change management and acceleration (e.g., CAP, Workout), and/or other available performance improvement methodologies to achieve these goals. Facilitates integration of methodology with quality improvement goals of the departments. Related responsibilities include, but are not limited to the following:

• Leading, facilitating and coordinating projects to improve clinical and non-clinical areas. Provides leadership in meeting goals and objectives.
• Developing and managing action plans and measurements of success data to ensure institution-wide oversight of all

regulatory compliance needs. 

• Working with functional and departmental leaders to develop action plans, corresponding timetables and monitors

action plans and results.

• Validating evidence of action plans and measurements of success data related to regulatory compliance issues

institution-wide for the hospital.

Demonstrates support for the mission, values and goals of the organization through behaviors that are consistent with the CT Children’s STANDARDS.

Education Required: Bachelor’s degree in health related field required

Education Preferred: Master’s preferred. 

Experience Required: Experience with accreditation survey processes required. 

5 – 7 years of progressive clinical experience. 3 – 5 years’ experience in project management.

Experience Preferred: Experience with CAP, Workout and LEAN preferred. 

LICENSE and/or CERTIFICATION REQUIRED

Current healthcare licensure in the state of Connecticut, RN preferred

KNOWLEDGE, SKILLS AND ABILITIES REQUIRED

KNOWLEDGE OF:

The Joint Commission (TJC) and Department of Public Health (DPH) standards

Performance improvement principles and how they relate to daily management decisions, strategic planning, operational decisions and organizational change. 

CMS Conditions of Participation

SKILLS:

Proven analytical/problem-solving skills. 

Outstanding communication, presentation and facilitation skills. 

Strong computer skills (e.g., Microsoft PP and Excel).

Strong project management skills.

Highly proficient planning skills.

ABILITY TO:

Successfully lead process change

Influence others to successfully implement process improvements

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