TRA USPI Interim Quality Director

Overview

Who We Are

We are a community built on care. Our caregivers and supporting staff extend compassion to those in need, helping to improve the health and well-being of those we serve, and provide comfort and healing. Your community is our community.

Our Story

We started out as a small operation in California. In May 1969, we acquired four hospitals, some additional care facilities and real estate for the future development of hospitals. Over the years, we've grown tremendously in size, scope and capability, building a home in new markets over time, and curating those homes to provide a compassionate environment for those entrusting us with their care.

We have a rich history at Tenet. There are so many stories of compassionate care; so many 'firsts' in terms of medical innovation; so many examples of enhancing healthcare delivery and shaping a business that is truly centered around patients and community need. Tenet and our predecessors have enabled us to touch many different elements of healthcare and make a difference in the lives of others.

Our Impact Today

Today, we are leading health system and services platform that continues to evolve in lockstep with community need. Tenet's operations include three businesses - our hospitals and physicians, USPI and Conifer Health Solutions.

Our impact spreads far and deep with 65 hospitals and approximately 510 outpatient centers and additional sites of care. We are differentiated by our top notch medical specialists and service lines that are tailored within each community we serve. The work Conifer is doing will help provide the foundation for better health for clients across the country, through the delivery of healthcare-focused revenue cycle management and value-based care solutions.

Together as an enterprise, we work to save lives and can accept nothing less than excellence from ourselves in service of our patients and their families, every day.

Job Summary

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:

• 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.
• 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.
• 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).
• Be a higher-level expert of the facility leaders in safety practices and formulation of goals and targets.
• 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

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

4

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

5

• 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

• 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

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

Experience

• At least five years of experience working in a quality / performance improvement and / or patient safety department.
• 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:

• Certified Professional Healthcare Quality (CPHQ) [Preferred]
• Certified Joint Commission Professional (CJCP) [Preferred]
• Certified Professional Healthcare Risk Management (CPHRM) [Preferred]

Organization Description

Careers at Tenet

At Tenet Healthcare, the heart of what we do centers on caring with compassion, which ultimately creates a bond between our caregivers and patients. Everyone contributes to these moments, whether providing care directly or supporting those who do.

As an organization, we provide employees with resources, tools and support to serve our patients and customers in the best way possible. We also take care of one another, helping team members further develop their career pathways and maximize their potential.

Employment practices will not be influenced or affected by an applicant's or employee's race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.

Tenet participates in the E-Verify program. Follow the link below for additional information.

E-Verify: http://www.uscis.gov/e-verify

The employment practices of Tenet Healthcare and its companies comply with all applicable laws and regulations.

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