Job Attributes

Work Schedule/Shift

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Job ID


Req. No


Job Title

Program Director System Policy


CHRISTUS System Office




Not Defined






CHRISTUS Health-68600


919 Hidden Ridge
Irving, TX  75038


Full Time

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The Program Director, System Policy supports the CHRISTUS Health quality mission of 'Zero Harm' through the development of high reliability system policy processes. The Program Director, System Policy must have clinical knowledge and expertise to support effective policy management in compliance with Federal, CMS, State, Joint Commission and other regulatory bodies, as this focus is foundational in moving towards the CHRISTUS Health vision. This function includes the development, implementation, maintenance, governance, and assessment of policy and procedure programs, including oversight in selection, development, and management of a system policy management application tool. The Program Director, System Policy collaborates with subject matter experts across all regions, departments, and facilities to develop and promote coordination and alignment of policy and procedure reference and continuous use management activities. The Program Director, System Policy will have a global view of the organization and is expected to bring high-reliability processes and information governance strategies to the performance of job responsibilities. The incumbent must be a proactive and decisive person who adapts well to and initiates changes in policy and procedure and application tools. These activities will decrease exposure to risks, increase quality patient care and steward financial and human resources and perform duties and responsibilities in a manner consistent with CHRISTUS Health Mission, Values, and Service Standards.


Policy and Procedure

A. Develops, implements and maintains programs ensuring the organization's policies and procedures are accurate, accessible, and consistent with accreditation, regulatory and organizational requirements.
B. Identify and assist all policy owners with additional methods for ensuring appropriate education on policies -- coordination of policy and procedure demonstrations, creation of education modules
C. Drives policy integration and committee structure of CHRISTUS Health key clinical activities with Joint Commission Standards, CMS Regulations and State Regulations to provide consistent processes across the CHRISTUS Health Ministries. The regulatory requirements must be weaved into every process within CHRISTUS Health whether or not the organization is Joint Commission accredited.[FK1]
  • Leads, directs and organizes interdisciplinary teams for Policies and Procedures.
  • Foster alignment and engagement within the organization with policy owners.
  • Foster involvement in Service Line Teams, assist with determination of resources and best practices based on Evidence Based Medicine as polices come through committee for review/revision
D. Support development of policies in collaboration with subject matter experts and audit policies for format, department overlap, regulatory requirements, etc.
E. Maintains a crosswalk of regulatory requirements (TJC, CMS, State) and appropriate policies, update routinely and when regulatory requirements changes, notify appropriate policy owners.
F. Working with System Director, Health Outcomes & Analytics to develop and execute assessment plan of policy effectiveness, including but not limited to high-reliability practices following reference policies and continuous use policies.

Policy Management Application Tool

G. Continuously evaluates and maintains chosen system application tool for Policy and Procedure Library within the CHRISTUS Health System Office:

To include:

  • Maintains policy and procedure document archives (electronic and hard copy) to ensure timely retrieval as needed for organizational and regulatory requests.
  • Develop and manage electronic tracking for changes to policies and procedures prior to and post approval, including key data governance principles
  • Evaluates pages according to CHRISTUS Health Intranet Governance Plan and works with owners and super users to correct changes, as needed
  • Collaborates with CHRISTUS Health tool Administrator/stakeholders, as needed for software upgrades and other changes to the tool environment to meet the needs of CHRISTUS Health users
  • Serves as a resource for tool management
  • Monitors content posted on site for appropriateness
  • Modifies or removes inappropriate or inaccurate tool content

Performs all duties in a manner that protects the confidentiality of patients and does not solicit or disclose any confidential information unless it is necessary in the performance of assigned job duties.

  • Bachelor of Science or higher degree in Nursing or clinically related field required, Master's degree preferred
  • Demonstrated competency in policy development and application management tool, such as SharePoint required
  • Strong working knowledge of regulatory standards for acute and ambulatory care settings
  • Excellent communication, prioritization, organizational and management skills
  • Computer literacy (Microsoft Office, clinical applications, policy management tools, and communications tools, such as SharePoint)
  • Ability to develop effective presentations and reports for leaders
B. Experience
  • Minimum 7 years of acute healthcare experience
  • Previous experience facilitating teams or leading projects
  • Must have experience in developing policies & procedures, with attention to meeting regulatory guidelines as a basis for design of policy
  • Must have experience in working with teams and with conflict resolution
C. Licenses, Registrations, or Certifications
  • Must maintain current professional licensures
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