JOB DESCRIPTION:
POSITION PURPOSE:

• Oversee clinical and operational assessments/surveys of Tenet hospitals (acute and surgical) and USPI entities (Surgical hospitals, ASCs) to ensure compliance with regulatory requirements, accreditation standards, and other regulatory agencies. ( e.g., TJC, CMS, DNV, AAAHC, OIG, and others)
• Responsible for the planning, coordinating and management of Quality Management Comprehensive Clinical Assessments, Disease Specific Certification assessments, ASC Mock surveys, focused reviews, and other reviews as determined by leadership.
• Collaborate with other corporate departments and groups in the development and implementation of policies and education related to regulatory and accreditation issues.
• Monitor regulatory and accreditation changes, and recommend revisions to the companyâ��s strategy related to regulatory changes
• Tenet corporate liaison with regulatory and accrediting agencies for changes, standards development and surveys including scheduled, unannounced and sentinel event visits.
• Responsible for collaborating and aiding Acquisition and Development in assisting with Due Diligence and coordination of surveys for new acquisitions.
• Prepare reports of assessment and survey findings for review by senior leadership, Regulatory Counsel, key hospital and market personnel and others as needed.
• Monitor implementation of corrective plans of action, provide guidance on accreditation and regulatory communications, assist in the development of plans, and review and approve plans.
• Provide consultation to hospitals regarding accreditation and regulatory concerns and needs, including monitoring of corrective action plans related to TJC, CMS, and other regulatory compliance.
• Upon request of hospital or senior management, arrange and provide other services such as focused reviews, special site-visits, and assistance.

MAJOR AREAS OF RESPONSIBILITY:

• Coordinate and act as resource to Tenet & USPI facilities on compliance to standards and regulations to assist in survey preparedness, Devaluate compliance issues, resource materials and arrange and perform requested site visits.
• Directs and provides leadership for professional staff performing Comprehensive Clinical Assessments, focused review and disease specific certification assessments and support staff.
• Develops, coordinates, and manages the Comprehensive Clinical Assessment process, follow-up visits and identification of patterns and trends. Development of tools, audit methodology and reports.
• Acts as a liaison and resource for facility and corporate departments for TJC and CMS Conditions of Participation.
• Upon request, provide support and assistance to other departments in review of clinical and regulatory concerns (i.e., Compliance, Legal, Risk Management, Patient Safety, and Clinical Informatics).
• Corporate liaison with Accrediting Organizations for surveys, special visits, appeals, special needs.
• Monitors regulatory/standard changes and prepares material to educate both internal and external audiences regarding the impact and recommended responses to the changes
• Provides presentation to both large and small groups regarding TJC/regulatory compliance and other related issues.

SKILLS, KNOWLEDGE AND ABILITIES:

• Conduct clinical and operational surveys of facilities including the review of Regulatory and Accreditation, Conditions of Participation, state requirements, etc.
• Expert at remediating findings when in a facility.
• Adept at developing methods, tools, reports, data aggregation and conducting clinical and operational surveys for Tenet facilities, including the review of regulatory requirements and accreditation standards and Conditions of Participation.
• Prepare written reports of clinical and operational survey findings.
• Skilled in developing corrective action plans, provide educational programs, monitor implementation of action plan and other oversight activities through follow-up visits to facilities as needed, and provide guidance on regulatory and accreditation communications as needed.
• Expert on regulatory requirements and accreditation standards, preparation activities, and success with surveys.
• Trained on outcomes and quality management and using and applying quality management diagnostic tools (defect analysis, fault tree analysis).
• Knowledgeable in the areas of peer review, risk management, patient safety, infection control prevention and reporting.
• Polished communicator (written, verbal and presentation skills) with many levels of key stakeholders from the board level to the point of care staff.
• Expert on TJC, Centers for Medicaid and Medicare, Quality Improvement Organization (QIO), state requirements and other regulatory standards / processes.
• Expert with working, leading, following, coordinating, and managing activities to driving change within Tenet to achieve strategic initiatives for clinical / operational initiatives related to regulatory accreditation.
• Adept at managing multiple large projects at one time.
• Identifies potential or actual regulatory/accreditation risk issues at individual or multiple facilities that can impact regulatory/accreditation compliance and pose a financial or reputational risk to the facility or company and immediately reports those findings to senior leadership

SUPERVISING THE WORK OF OTHERS:

• Interview candidates and make hiring decisions.
• Orient new subordinates regarding Company or department policies/procedures and what is expected of them in the way of performance results and standards. Review their position responsibilities with them.
• Establish performance standards for the quality of work subordinates are expected to achieve
• Delegate, control, and review work assignments of direct reports.
• Train, develop, motivate, and counsel direct reports to improve their present performance and to prepare them for higher-level positions.
• Communicate to all individuals and/or departments involved any developments or information necessary for them to fulfill their responsibilities.
• Communicate and administer human resources programs and procedures in accordance with established policies.
• Periodically review the position descriptions of subordinates for accuracy. Document and resubmit for evaluation if warranted.
• Periodically review the human resource needs of the organizational unit and recommend increases and decreases in staff.
• Evaluate the performance of direct reports. Discuss present and past performance, establish new objectives, accountabilities and develop plans. Counsel employees: recommend corrective action as warranted. Keep the next level supervisor informed of discussion results.
• Review salaries of direct reports and determine increases, promotions, transfers, and demotions as warranted.
• Remains current concerning industry-wide, clinical care leading practices and evaluates for implementation in Tenet.
• Demonstrates ethical behavior in decision-making, performance of job responsibilities while maintaining confidentiality regarding patient information, quality, performance, and peer review information.
• Prepares reports and presents to various audiences using statistical process control.

PRIMARY INFORMATION, TOOLS AND SYSTEMS USED:

• PC based Word and Excel spreadsheet programs
• Industry publications as they relate to Regulatory/Accreditation and other areas, as applicable, such as Safety, Risk Management, etc.
• Electronic Health Record
• eSRM (Risk Management System)
• Balanced Score Card / Clinical Operations Scorecard
• SharePoint
• AMP with Tracers

REQUIRED SKILLS:
REQUIRED KNOWLEDGE AND EXPERIENCE:

• RN degree preferred. Masterâ��s degree in healthcare related field required
• Active RN professional license or other professional license if relevant
• Greater than 7 years of progressive leadership experience in a hospital required. Prefer experience leading a complex hospital or a multi-hospital system in Regulatory and Accreditation or Quality department
• Certified Professional Healthcare Quality or Certified Professional Joint Commission preferred but required to obtain with one year of hire
• Thorough knowledge of regulatory and accreditation requirements
• Relevant clinical experience
• Strong organizational skills as well as written skills

Tenet complies with federal, state, and/or local laws regarding mandatory vaccination of its workforce. If you are offered this position and must be vaccinated under any applicable law, you will be required to show proof of full vaccination or obtain an approval of a religious or medical exemption prior to your start date. If you receive an exemption from the vaccination requirement, you will be required to submit to regular testing in accordance with the law.

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.