TRA USPI Interim Quality Director

The Patient Safety Director will be the functional domain thought and impact leader for safety at Tenet and interact with similar level functional leaders (e.g., Safety, Regulatory, Infection Prevention) as a team to build an integrated plan for impact.  This position is responsible for building a safety agenda that bridges across the three business units (e.g., Acute Care Hospitals, USPI, and TPR), and extending vertically to up-skill and develop the facilities’ Patient Safety Officer (PSO) .  In addition, he/she will ensure adherence with Patient Safety Regulations & Accreditation.  Excellence in this role would be driving safety outcomes Tenet-wide while radically up-skilling and up-willing PSOs at the facilities.  More specifically, this position will:

1. Develop a safety agenda that solves our performance opportunities, incorporates proven practices, and distilled to a manageable clarity so that it is easier to implement, train, track, and goal against valid metrics and targets.
2. Work with peer knowledge domain leaders to build an integrated and mutually reinforcing “quality-safety-regulatory-infection prevention” plan.  By design this plan should overlap knowledge domains and maintain clarity of purpose with specificity. 
3. The position implements and supports processes which drive outcomes-based, evidence-based, cost-effective and safe practices in the multiple facilities setting (e.g., ACH, USPI, and TPR).
4. Be a higher-level expert of the facility leaders in safety practices and formulation of goals and targets.
5. Routinely support multiple facilities by providing them with advice, best practice tools and templates, connecting facilities with each other for enhanced knowledge sharing, and researching information on their behalf.

Collaborate with the multiple facilities’ CEO, CNO, COO, CMO, Patient Safety Officers, and DCQIs to adhere to applicable federal, state, local regulations. These include but are not limited to The Joint Commission, EMTALA, FDA reporting, etc.

Responsibilities MAJOR AREAS OF RESPONSIBILITY: Beginning with the most important, briefly state the major duties and responsibilities of this job, percent of total job, frequency of each activity and whether or not it is an essential function.  An essential function is a basic, necessary, and a required part of the job.  Is this function necessary to fulfill the job duties? Priority

Duties & Areas of Responsibility

(what this person does)

% of Total Job (should = 100%)

Frequency

(daily, weekly, monthly, etc.)

Essential Functions?

(yes/no)

1 Patient Safety - Provides oversight to the Patient Safety Officer, in collaboration with the Tenet Quality & Patient Safety Department, in executing all domains of practice (Claims and Litigations, Even Reporting System Management, Conducting Case Investigations, Facilitating Event Review, Risk Financing, Management Device Failures, Legal and Regulatory, Concerns and Grievances, Patient Safety Operations & leading Company Standard Work Initiatives, Proactive Risk Assessment, and Ethical Issues [Consultant]). 33%   YEs 2 Patient Safety - Provides oversight and supports processes for managing post event diagnostics, adverse event disclosure, and shared learning across the facility for prevention of ongoing events.     3

1. Patient Safety - Verifies adherence to the Tenet Operating System for Patient Safety for managing the Patient Safety Reporting System (PSRS) and reporting.

    4

1. Patient Safety - Supports facility with the development of sentinel event corrective action plans and follow-up on measures of success within specified timeframes.

    5

1. Patient Safety - Supports the Patient Safety Officer’s to execute robust process improvement and other auditing/monitoring process.

    6 Patient Safety - Verifies facilities have ethics committee structure with guidelines for handling bio-ethical issues.     7

1. Patient Safety - Verifies that Tenet Standard Work initiatives are in place and are supported by robust process improvement plans.

    8

Regulatory & Accreditation - 

Verifies facility is prepared for surveys (i.e., State, TJC, CMS and others), in collaboration with the Tenet Quality and Patient Safety Department. 

33%     9 Regulatory & Accreditation - Supports regulatory & accreditation quality managers during informal and formal facility reviews on identified issues per the Tenet Quality and Patient Safety strategy and tactics.      10 Regulatory & Accreditation - Collaborates with quality manager in assessing the progression and sustainment of regulatory and accreditation strategy and tactics.      11 Regulatory & Accreditation - Supports development and use of Tenet methods, tools, and other resources for regulatory and accreditation preparedness and sustainment.     12 Regulatory & Accreditation - Supports implementation and sustainment for successful regulatory and accreditation preparation and surveys.     13 Regulatory & Accreditation - Supports the facility in the formulation of responses [plans of correction] from regulatory and accrediting organizations and third party payers under the direction and approval of the Tenet Quality & Patient Safety Department.     14 Regulatory & Accreditation - Collaborates with quality managers in the assessing adherence and sustainment of corrective action plans.     15 Clinical Measures - Supports Tenet Quality and Patient Safety Department balanced scorecard/clinical service scorecard and facility goals, including participation in publicly reported data (Leapfrog, AHRQ survey), and targets through collaboration with assigned facility DCQIs.  33%     16 Clinical Measures - Routinely visits facilities to review quality, safety, service, and regulatory type items     17 Clinical Measures - Supports implementation and sustainment of clinical process improvements through analysis and summarization of reports.     18 Clinical Measures - Ongoing monitoring of facilities’ progress with safety action plans (e.g., AHRQ, SREs, FMEA status), regulatory action plan follow-up.     19 Clinical Measures - Monitors and addresses need for intervention or elevates to appropriate person, as needed, based on measure performance.     20 Clinical Measures - Verifies facility has a process in place to adhere to the Operative and Invasive Policy and Procedures.        SUBORDINATES: Employees supervised by this position   Exempt Non-Exempt Total number of employees directly reporting to this position (if any): ~2 0 Total number of employees indirectly reporting to this position (if any): ~30-40 0              
Qualifications

Education

1. Registered Nurse (RN) BSN degree required, with experience in quality / performance improvement, and as applicable in other related areas of responsibility.
2. Advanced degree in a health related field (Masters or Doctorate) preferred, with 5 years of relevant facility preferred management experience
3. Current nursing licensure

Experience

1. At least five years of experience working in a quality / performance improvement and / or   patient safety department.
2. At least five years of experience leading interdisciplinary initiatives in process improvement or directly improving the reliability of healthcare delivery at the point of care.     

Certification:

1. Certified Professional Healthcare Quality (CPHQ) [Preferred]
2. Certified Joint Commission Professional (CJCP) [Preferred]
3. Certified Professional Healthcare Risk Management (CPHRM) [Preferred]

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