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Position Summary:

The **Vice President of Safety and Regulatory Affairs** is a senior executive responsible for leading the hospital’s enterprise-wide strategies in **patient safety** and **regulatory compliance** . Reporting to the **Chief Medical Officer (CMO)** , this role is critical in developing and sustaining a high-reliability culture that prioritizes the safety of patients, staff, and visitors. The VP oversees incident management, risk mitigation, policy development, and proactive strategies to reduce harm while supporting the hospital’s mission of delivering safe, high-quality, and patient-centered care. The VP of Safety and Regulatory Affairs also directs development and implementation of a system wide accreditation program to ensure continuous compliance with all federal and state regulatory standards (The Joint Commission, CMS, DPH, MA BORIM). The position requires expert knowledge in federal, state and TJC standards and clinical and operational expertise to achieve and maintain a continuous state of readiness. This includes, but is not limited to, functioning as an expert resource and consultant to the organization, as a liaison between the organization and accreditation or regulatory bodies, and as a resource in continuous improvement activities

Key Responsibilities:

Patient Safety Leadership

+ Direct and continuously improve the hospital’s **Patient Safety Program** , including serious safety event (SSE) identification, response, and follow-up.

+ Facilitate **Root Cause Analyses (RCAs)** and **Failure Mode and Effects Analyses (FMEAs)** , ensuring systemic improvements are implemented and sustained.

+ Champion a **Just Culture** environment that promotes transparency, learning, and non-punitive reporting of errors.

Risk Management and Mitigation

+ Partners with **clinical risk management** , to lead safety event investigation, risk assessment, and reduction strategies.

+ Oversee internal event reporting systems, ensuring timely documentation, response, and risk mitigation.

+ Serve as the primary liaison with legal counsel on claims, litigation, and potential liability exposure.

Regulatory Compliance and Accreditation

+ Ensure organizational compliance with all regulatory standards related to patient safety and risk, including **The Joint Commission (TJC)** , **Centers for Medicare & Medicaid Services (CMS)** , **OSHA** , and **state health departments** .

+ Lead survey readiness and response activities, including mock surveys, staff education, and policy alignment.

+ Monitor and update internal policies and procedures to maintain alignment with evolving regulatory standards.

Safety Culture Development

+ Drive the hospital’s transformation into a **High Reliability Organization (HRO)** by leading cultural initiatives that embed safety as a core value.

+ Engage physicians, nurses, and administrative staff in safety improvement efforts and accountability structures.

+ Promote awareness and education across the organization through training, safety rounds, and communication campaigns.

Data, Reporting, and Analytics

+ Analyze safety and risk data trends and translate insights into actionable strategies for improvement.

+ Develop and present dashboards and reports for senior leadership, the Board Quality and Safety Committee, and regulatory bodies.

+ Track key performance indicators (KPIs) such as hospital-acquired conditions (HACs), serious safety events (SSEs), patient complaints, and malpractice claims.

Leadership and Team Development

+ Lead a multidisciplinary team including patient safety officers, risk managers, and event coordinators.

+ Foster collaboration across departments including nursing, medical staff, quality, compliance, and operations.

+ Support recruitment, development, and retention of high-performing team members within the safety and risk function.

Drug Diversion Management

+ Oversees BH Diversion Management Program

Minimum Qualifications:

+ Master’s degree in Healthcare Administration, Nursing, Risk Management, Public Health, or a related field.

+ Minimum of 10 years of healthcare experience, including 5+ years in a leadership role related to patient safety or risk management.

+ Strong knowledge of hospital operations, clinical workflows, and safety science principles.

+ Familiarity with regulatory standards from TJC, CMS, and other relevant agencies.

Preferred Qualifications:

+ Clinical licensure (e.g., RN, MD, DO) highly preferred.

+ Certified Professional in Healthcare Risk Management (CPHRM), Certified Professional in Patient Safety (CPPS), or related credential.

+ Demonstrated experience leading RCA, FMEA, and high-reliability initiatives.

+ Excellent analytical, communication, leadership, and conflict resolution skills.

You Belong At Baystate

At Baystate Health we know that treating one another with dignity and equity is what elevates respect for our patients and staff. It makes us not just an organization, but also a community where you belong. It is how we advance the care and enhance the lives of all people.

DIVERSE TEAMS. DIVERSE PATIENTS. DIVERSE LOCATIONS.

Education:

Certifications:

Equal Employment Opportunity Employer

Baystate Health is an Equal Opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, marital status, national origin, ancestry, age, genetic information, disability, or protected veteran status.