Director, Facilities Environment of Care (EOC), Quality & Compliance

POSITION SUMMARY:

The Director, Facilities EOC, Quality & Compliance for Boston Medical Center Health System, is responsible for ensuring that each campus' physical facilities comply with all applicable regulatory requirements, including federal, state, and local regulations. The Director will report to the Senior Director, Facilities Operations, BMCHS.

Position: Director, Facilities Environment of Care (EOC), Quality & Compliance

Department: Facilities

Schedule: Full Time

Location: Onsite, with the ability to travel to all BMC properties.

ESSENTIAL RESPONSIBILITIES / DUTIES:

This role involves developing, implementing, and managing programs related to safety, environmental health, life safety codes, and emergency preparedness. The Director serves as the key liaison with regulatory agencies and is responsible for preparing for and responding to inspections, audits, and accreditation processes. The Director will lead an interdisciplinary team accountable for enabling activities focused on maintaining and improving quality, compliance, and written standards.

Work Performed:

• Assess status of Facilities' Areas of Responsibility at BMC, GSMC and SEMC to estimate risk
• Oversee Requirements for DPH and Joint Commission Environment of Care (EOC), Life Safety and Compliance for all facilities in a consistent program format
• Handle all EOC Infection Control Reporting (i.e. air quality testing, Legionella reporting, etc.)
• Implement and ensure consistency of reporting across all four hospitals
• Boston Fire Liaison/Brockton Fire Liaison (Inspection, quarterly testing and communication)
• Environmental tours with each Hospital and Community Health centers Compliance Team to ensure EOC hospital compliance

Position Overview
Regulatory Compliance:

• Ensure hospital facilities comply with all applicable regulations, including those set by the Joint Commission (TJC), OSHA, CMS, NFPA, and local/state authorities.
• Stay up to date on changes to regulations and ensure that facility operations meet new standards.
• Coordinate facility inspections and regulatory audits, and manage any corrective actions required.

Safety and Environmental Health:

• Develop and manage safety and environmental health programs, ensuring compliance with regulations and best practices.
• Oversee each hospital's hazardous materials program, including the handling, storage, and disposal of hazardous substances.
• Conduct routine safety audits, inspections, and risk assessments across all hospital facilities.

Life Safety Code Compliance:

• Ensure compliance with NFPA Life Safety Code and other fire safety regulations.
• Work with the hospital's fire safety and emergency preparedness teams to conduct drills and maintain documentation.
• Develop and implement fire prevention and life safety policies and procedures.

Emergency Preparedness:

• Collaborate with the emergency management team to develop, implement, and test the hospital's emergency preparedness plan.
• Oversee the training of staff in emergency procedures and ensure compliance with CMS emergency preparedness requirements.
• Ensure all emergency systems (e.g., generators, water supply, alarm systems) are functional and compliant.

Documentation and Reporting:

• Maintain comprehensive records of inspections, certifications, and regulatory reports.
• Develop reports and provide updates to hospital leadership on compliance-related issues and findings.
• Respond to requests for information from regulatory bodies and participate in meetings or hearings as needed.

Facilities Management Collaboration:

• Collaborate with engineering, maintenance, and operations teams to ensure that physical infrastructure and equipment comply with all relevant safety and regulatory standards.
• Work with project managers on construction and renovation projects to ensure they meet compliance standards from the design phase through completion.

Training and Staff Education:

• Design and implement training programs for staff on compliance-related topics, including safety protocols, environmental health, and emergency procedures.
• Ensure all facilities staff are aware of their roles and responsibilities in maintaining compliance.

Leadership and Supervision:

• Lead a compliance team, providing direction, supervision, and development.
• Serve as the primary contact for hospital leadership on matters related to facility compliance.
• Engage with various hospital departments to ensure organization-wide adherence to compliance standards

JOB REQUIREMENTS

EDUCATION:

A minimum of a Bachelor's Degree is required

CERTIFICATES, LICENSES, REGISTRATIONS REQUIRED:

None

EXPERIENCE:

Minimum of 7-10 years of experience in healthcare facilities management, with specific experience in compliance and safety programs

KNOWLEDGE, SKILLS & ABILITIES (KSA):

• Demonstrated experience and strong knowledge of quality & compliance practices across hospitals as well as regulatory expectations, i.e. Joint Commission, NFPA, OSHA, CMS, DPH, Boston and Brocton Fire.
• Critical thinking with proven ability to identify and implement new solutions and enterprise-wide thinking.
• Influential leadership, tailors approach to influence and empower others.
• Ability to act as an ambassador for and champion innovation and change.
• Demonstrates robust judgment, problem solving and decision making. Ability to apply critical and analytical thinking and use data and insight to develop effective solutions. Ability to handle complex and ambiguous issues.
• Excellent collaborator with emotional intelligence and the ability to read and manage interpersonal dynamics and apply conflict resolution skills.
• Excellent organizational and project management skills.
• Ability to work collaboratively with interdisciplinary teams.
• Strong verbal and written communication skills.
• Proficiency in safety and compliance management systems.

Equal Opportunity Employer/Disabled/Veterans