Director Facility Regulatory Outcomes

The Director of Facilities Regulatory Outcomes provides system-level leadership and oversight for regulatory compliance, policy development, and authority having jurisdiction (AHJ) coordination across all FMOLHS hospitals, clinics, and support facilities.
Reporting to the Vice President of Construction and Facility / Plant Operations, this role ensures all markets maintain consistent compliance with Joint Commission, CMS, NFPA, OSHA, EPA, and state/local requirements related to environment of care (EOC), life safety, and utilities management.
The Director develops and standardizes policies, processes, and procedures for inspection, testing, and maintenance (ITM) programs across all markets. This includes regulatory documentation, reporting accuracy, and audit readiness for AHJ inspections and surveys.
This position acts as the system’s subject matter expert for facility regulatory performance — guiding market facility directors, coordinating with Safety and Quality departments, and ensuring that every FMOLHS facility achieves consistent, survey-ready outcomes.
The Director serves as a bridge between system governance and operational execution, driving standardization, accountability, and proactive risk mitigation across the entire FMOLHS footprint.

• Regulatory Oversight & Compliance Leadership –
  Develop, implement, and maintain system-wide policies and procedures governing compliance with Joint Commission, CMS, NFPA, OSHA, EPA, and state/local AHJs.
  Monitor market adherence to established standards and ensure timely updates to reflect regulatory changes.
  Coordinate with Legal, Safety, and Quality teams to ensure consistent interpretation and implementation of regulations.
• Authority Having Jurisdiction (AHJ) Coordination –
  Serve as the primary system liaison with external regulatory authorities, surveyors, and inspectors.
  Ensure each market maintains current documentation and testing records required for AHJ reviews.
  Oversee responses to survey findings and ensure system-level corrective action plans are developed, implemented, and verified.
• Policy, Process & Procedure Development –
  Design and maintain the FMOLHS Facilities Regulatory Manual, outlining standards for ITM, documentation, reporting, and escalation.
  Lead the review and approval process for all policy changes affecting facilities, utilities, and life safety.
  Ensure uniform implementation and audit readiness across markets.
• Data Management & Reporting –
  Develop a system-wide regulatory performance dashboard that consolidates survey outcomes, inspection findings, and compliance metrics.
  Ensure data integrity, timely reporting, and actionable analysis for system and executive review.
  Identify trends, risks, and opportunities for improvement based on regulatory outcomes.
• Training & Market Support –
  Provide ongoing education and competency development for market facility directors, safety officers, and maintenance teams. Facilitate system-level training on Joint Commission standards, CMS CoPs, and NFPA requirements. Support new facility onboarding and transitions with regulatory orientation and readiness guidance.
• Survey Readiness & Continuous Improvement –
  Lead mock surveys and internal audits to evaluate readiness and close performance gaps.
  Promote a culture of proactive compliance, emphasizing prevention over correction.
  Collaborate with the VP and Senior Director of Facilities to drive continuous improvement in regulatory performance across all FMOLHS facilities.
  
  

• Bachelor's Degree required
• 7 years' experience in Healthcare Facilities Operations Regulatory Outcomes