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The Program Manager, HB2697 Staffing Governance & Compliance is responsible for the day-to-day execution, coordination, and continuous improvement of OHSU’s staffing governance and regulatory compliance processes under Oregon House Bill (HB) 2697.

Reporting to the Senior Director, this role operationalizes governance structures, workflows, and compliance systems, ensuring that staffing committees, escalation pathways, and regulatory processes function consistently, efficiently, and in alignment with organizational expectations.

The Program Manager serves as the primary system operator for staffing governance—coordinating committee activities, managing staffing plan workflows, tracking compliance performance, and supporting regulatory response processes.

This role does not establish staffing policy, staffing levels, or governance structures, but instead ensures the reliable execution, documentation, and monitoring of those established by executive leadership, clinical leadership, and labor agreements.

The Program Manager partners closely with the Senior Director and cross-functional stakeholders (including but not limited to: Legal, Labor Relations, Regulatory Affairs, Nursing, Finance, and operations leadership) to ensure a standardized, audit-ready, and defensible governance system that minimizes compliance risk and supports effective decision-making.

Staffing Governance & Committee System Leadership

• Monitors and manages governance operations (e.g., decision timelines, escalation utilization, workflow adherence) and escalates performance gaps or risks to the Senior Director 
• Supports Executive Governance Council by preparing analyses, summaries, and escalation materials for high-risk or unresolved issues
• Coordinates day-to-day operations of the HB2697 staffing governance system, including staffing committees (Professional Technical & Service and Nursing), escalation pathways, and executive governance processes 
• Manages logistics, facilitation support, and workflow coordination for governance forums (Staffing Committee, Steering Committee, Executive Governance Council) to ensure timely, consistent, and compliant execution 
• Partners with committee co-chairs, Labor Relations, and operational leaders to prepare structured agendas, decision-support materials, and ensure readiness for governance discussions 
• Ensures adherence to established governance processes, including decision rights, quorum requirements, documentation standards, and escalation protocols 
• Tracks committee decisions, action items, and follow-ups to ensure closure and accountability 
• Implements and maintains standardized workflows for staffing plan development, review, approval, and revision 
• Ensures appropriate use of escalation pathways and facilitates coordination when governance thresholds (e.g., quorum, impasse) are not met 
• Provides leadership with clear, accurate visibility into governance activities, risks, and process performance through reporting and documentation

Safe Staffing Plan Governance & Administration

• Manages the end-to-end lifecycle of the enterprise staffing plan portfolio, including intake, tracking, version control, review workflows, approvals, and submission readiness 
• Ensures staffing plans meet defined statutory, operational, and documentation requirements prior to submission, based on established standards and guidance 
• Maintains centralized documentation and audit-ready records of all staffing plans and revisions 
• Tracks plan status, approvals, and timelines, ensuring transparency and accountability across stakeholders 
• Supports alignment of staffing plan documentation with organizational standards and regulatory expectations; escalates inconsistencies or risks.

Data, Reporting, & Audit Readiness

• Maintains data infrastructure, reporting tools, and dashboards supporting staffing governance, compliance tracking, and risk visibility 
  
• Ensures accuracy, completeness, and audit readiness of all governance, compliance, and investigation data and documentation 
  
• Produces routine and ad hoc reports on staffing plans, deviations, escalations, investigations, and compliance performance 
  
• Develops and maintains centralized dashboards to monitor key indicators (e.g., deviations, investigations, penalties, plan approvals) 
  
• Tracks and reports compliance-related financial impacts (e.g., penalties, staffing deviations) in partnership with Finance 
  
• Uses data to identify trends, surface risks, and support decision-making by leadership.

Regulatory Compliance & Risk Management

• Executes and maintains processes required to support enterprise compliance with HB2697, including governance workflows, staffing plan requirements, and regulatory timelines
  
• Maintains standardized compliance workflows and tracking systems to ensure consistent and defensible application across service areas
  
• Monitors and tracks staffing plan deviations, safe harbor utilization, and required reporting timelines; ensures completeness and accuracy of documentation
  
• Identifies, documents, and escalates compliance risks, delays, or gaps to the Senior Director and appropriate stakeholders
  
• Coordinates escalation of plan delays, governance impasses, and high-risk compliance issues through established processes
  
• Partners with Legal, Labor Relations, and Regulatory Affairs to ensure workflows and documentation align with regulatory expectations and interpretations.

Investigation & Regulatory Response Leadership

• Coordinates enterprise response activities for staffing-related investigations, audits, and regulatory inquiries
  
• Collects, organizes, and validates data and documentation required for regulatory responses in partnership with Regulatory Affairs, Legal, Labor Relations, and Operations
  
• Tracks investigation timelines, deliverables, outcomes, and required follow-up actions
  
• Ensures completeness, accuracy, and audit readiness of all submitted materials
  
• Identifies trends or recurring issues contributing to regulatory risk and escalates to the Senior Director for resolution and system-level action.

Cross-Functional Leadership & Organizational Alignment

• Serves as a central coordination point across clinical operations, Labor Relations, Legal, Regulatory Affairs, HR, and other stakeholders involved in staffing governance
  
• Facilitates communication and information flow across governance forums and operational teams
  
• Supports consistent application of established processes and requirements across committees and service areas
  
• Coordinates resolution of operational issues by connecting appropriate stakeholders and ensuring follow-through
  
• Ensures timely escalation of risks, delays, and cross-functional issues to the Senior Director
  
• Exercises sound judgment in managing sensitive regulatory, labor, and organizational information.

Governance Performance & Continuous Improvement

• Tracks and reports key performance indicators (e.g., plan approval cycle time, escalation rates, deviation trends) to support governance effectiveness
  
• Identifies process gaps, inefficiencies, and variability in governance workflows
  
• Implements process improvements to enhance efficiency, consistency, and compliance, based on approved direction
  
• Supports standardization of workflows, documentation, and operating procedures across the governance system
  
• Partners with Regulatory Affairs, Legal, Labor Relations, and Communications to operationalize regulatory requirements into clear, usable processes and tools
  
• Reinforces consistent application of established definitions, guidance, and process standards across governance activities
  
• Maintains and updates governance process documentation, templates, and tools to support scalability and operational reliability

Other Duties as Assigned

• Bachelor’s degree and seven years of progressively responsible program/project management 
  experience OR
• Master’s degree and six years of progressively responsible experience OR
• Equivalent combination of education, training, and demonstrated experience.

Job Related Knowledge, Skills and Abilities (Competencies):

• Strong program and project management skills, including planning, coordination, and execution of complex workflows.
• Ability to manage multiple priorities, track deliverables, and ensure timely completion of tasks in a fast-paced environment.
• Ability to design, implement, and improve workflows, standard operating procedures, and tracking systems.
• High attention to detail with strong documentation and audit-readiness capabilities
• Ability to collect, validate, analyze, and present data to support decision-making
• Experience with reporting tools, dashboards, and performance tracking
• Strong interpersonal and communication skills with the ability to work effectively across diverse stakeholder groups.
• Ability to facilitate meetings, support structured decision-making processes, and ensure follow-through on actions.
• Working knowledge of regulatory and compliance environments in healthcare
• Ability to interpret and operationalize requirements into processes, tools, and workflows
• Ability to identify risks, gaps, and inefficiencies and escalate appropriately
• Exercises sound judgment in handling sensitive operational, regulatory, and labor-related information

• Master’s degree in healthcare administration (MHA), Public Health (MPH), or related field
• Experience with staffing operations, workforce planning, or labor-related environments
• Experience supporting regulatory programs (e.g., CMS, Joint Commission, DNV, ACGME, state workforce regulations)
• Experience building or maintaining reporting tools, dashboards, or tracking systems
• Experience supporting governance bodies, committees, or formal decision-making structures
• Project Management Professional (PMP) or equivalent certification
• Lean, Six Sigma, or other process improvement training