Manager Facilities Accreditation & Regulatory Compliance

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Mission Statement

Michigan Medicine improves the health of patients, populations and communities through excellence in education, patient care, community service, research and technology development, and through leadership activities in Michigan, nationally and internationally.  Our mission is guided by our Strategic Principles and has three critical components; patient care, education and research that together enhance our contribution to society.

Why Join Michigan Medicine?

Michigan Medicine is one of the largest health care complexes in the world and has been the site of many groundbreaking medical and technological advancements since the opening of the U-M Medical School in 1850. Michigan Medicine is comprised of over 30,000 employees and our vision is to attract, inspire, and develop outstanding people in medicine, sciences, and healthcare to become one of the world’s most distinguished academic health systems.  In some way, great or small, every person here helps to advance this world-class institution. Work at Michigan Medicine and become a victor for the greater good.

What Benefits can you Look Forward to?

  • Excellent medical, dental and vision coverage effective on your very first day
  • 2:1 Match on retirement savings

Responsibilities*

Regulatory Oversight Lead: Ensuring U-M Health is compliant with all regulatory oversight agencies, including:

  • The Joint Commission (TJC)
  • Centers for Medicare and Medicaid Services (CMS)
  • State Fire Marshall

Duties shall include, but not be limited to: 

  • Ensuring preparation in place for and acting as Lead for the Life Safety/TJC engineers on surveys, including oversight and coordination. 
  • Maintaining all regulatory compliance documents to current regulatory standards.
  • Ensuring all regulatory priority 4 & 5 preventative maintenance items are being tracked & completed against established performance metrics (KPIs).
  • Leading State of Michigan annual fire inspection tours.
  • Maintaining education/training for additional facilities staff in support of The Joint Commission accreditation surveys.
  • Tracking and maintenance of U-M Health regulatory compliance key plans.
  • Interface with SMS Director for elements of EOC chapter management.
  • Lead for the EOC Utilities Management and chapters of Life Safety applicable to Facilities Maintenance.
  • Track, manage and report out on the status of all Regulatory action plans/items.
  • Annual update of the ASHE Building Risk assessment to add any new buildings and/or new patient care areas within existing facilities.
  • Mange bi-weekly EOC rounding program.  Create work orders for deficiencies noted during rounding, provide status updates to Accreditation Team.
  • Represent Facilities Maintenance Operations on the Infection Control Committee.  Provide quarterly presentation to the group on facilities issues.
  • Partnering with Leadership and other departmental PMs in setting priorities and areas of improvement along with reporting on their status (progress) monthly. (TJC/CMS/Fire Marshall)
  • Leading teams in the Analysis and Measurement of the effectiveness of existing business processes and help develop and implement sustainable, repeatable and quantifiable business process improvements.
  • Facilitating After Action Reviews, SBARs, A3/PDCA and Workflow (Value Stream) Mapping in support of emerging Facilities Quality and Safety Issues.
  • Collecting and analyzing process data to initiate, develop and recommend business practices and procedures that focus on enhanced Quality, Safety, Productivity and Reduced Cost.

Required Qualifications*

  • Four-year BA or BS degree.
  • 5+ years of progressively responsible Regulatory oversight in Healthcare Facilities (Preferably having experience with 2+ TJC Survey Cycles and Action Plans).
  • 5+ years of progressively responsible project management/business process experience (as the assigned lead of projects).
  • 5+ years of Facilities Operations Experience (Healthcare preferred).
  • Knowledge of CMMS software with all modules.
  • Solid demonstration of verbal and written communications.
  • Knowledge of standard MS Office/365 and Teams software with all modules and associated applications.
  • Excellent Power Point creation skills.
  • Ability to work in teams.
  • Ability to lead teams.
  • Exceptional leadership and people skills.
  • Ability to act independently with minimal supervision or direction.
  • Able to make decisions and act upon them.

Modes of Work

Positions that are eligible for hybrid or mobile/remote work mode are at the discretion of the hiring department. Work agreements are reviewed annually at a minimum and are subject to change at any time, and for any reason, throughout the course of employment. Learn more about the work modes.

Underfill Statement

This position may be underfilled at a lower classification depending on the qualifications of the selected candidate.

Background Screening

Michigan Medicine conducts background screening and pre-employment drug testing on job candidates upon acceptance of a contingent job offer and may use a third party administrator to conduct background screenings.  Background screenings are performed in compliance with the Fair Credit Report Act. Pre-employment drug testing applies to all selected candidates, including new or additional faculty and staff appointments, as well as transfers from other U-M campuses.

Application Deadline

Job openings are posted for a minimum of seven calendar days.  The review and selection process may begin as early as the eighth day after posting. This opening may be removed from posting boards and filled anytime after the minimum posting period has ended.

U-M EEO/AA Statement

The University of Michigan is an equal opportunity/affirmative action employer.