Manager, Regulatory & Accreditation

Tenet Healthcare has an immediate opening for a Manager, Regulatory & Accreditation to support the enterprise. This is a position for a Registered Nurse leader (new for 2020), with expertise and knowledge of hospital Joint Commission survey preparedness and successful outcomes. The Manager will act as an internal consultant, traveling nationwide to advise our system hospitals. Position reports to system�s Senior Director, Quality Management.

Manager, Regulatory & Accreditation is responsible for assessing, developing, educating, implementing, monitoring, and leading the Tenet Regulatory and Accreditation activities within the company. This includes preparation and survey readiness. The position develops and implements processes for current safe practices in Tenet. The Manager, Regulatory and Accreditation work closely with other corporate departments, groups, and facilities for collaboration and synergy around identified priorities. The Manager assesses Tenet emergency management and refers disaster preparedness and business continuity to appropriate personnel.

OBJECTIVES

• Develops, educates, implements, monitors, and leads, Tenet, regulatory requirements and accreditation standards, goals and targets through collaboration with corporate departments and the Director Quality Patient Safety (DQPS).
• Is a leader for the Tenet Quality Department in the formulation of Tenet regulatory and accreditation related goals and targets.
• Employ a servant leadership approach to all work.
• Employs a transformational approach rather than transactional.
• Assists with the development of the Tenet strategy and tactics for regulatory and accreditation preparation and successful surveys
• Tracks progression and sustainment of the Tenet regulatory and accreditation strategy and tactics per standardized reporting process.
• Provides input for strategic development, planning and implementation of Tenet Quality Department Regulatory and Accreditation activities.
• Provides leadership and expertise in methods of preparation and sustainment of regulatory requirements and accreditation standards.
• Provides leadership and expertise in methods of performance improvement.
• Coordinates and collaborates with Tenet leaders on activities related to the development, implementation, improvement of and adherence to the organization�s policies and procedures covering the scope of regulatory requirements and accreditation standards
• Supports Tenet�s preparation for surveys (i.e., State, TJC, CMS and others)
• Conduct formal facility reviews.
• Supports the formulation of responses [plans of correction] from surveyors, electronic communication, or third party payers under the direction and approval of the Tenet Quality Management Department as needed.
• Prepares reports which displays the results of regulatory and accreditation activities and updates the Tenet regulatory requirements and accreditation standards plans and strategies as needed.
• Remains current concerning industry-wide, 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
• Facilitates, supports, and organizes process improvement and provides staff support services to such teams.
• Develops Tenet policies and procedures for areas of responsibility.
• Develops and uses Tenet methods, tools, and other resources for regulatory and accreditation preparedness and sustainment.
• Develops and presents educational material to various audiences based on identified or trending regulatory and accreditation issues.
• Travel of at least 75%, annually

Qualifications:

Minimum education, training and background for the successful candidate include:

1) Bachelors preferred, with experience in regulatory requirements and accreditation standards, performance improvement as applicable in other related areas of responsibility.

2) Masters degree strongly preferred

3) Knowledge of TJC and other regulatory standards.

4) Knowledge of CMS CoP Conditions of Participation and other federal and state requirements.

5) Knowledge of principles of quality improvement.

6) Relevant clinical experience.

7) Strong organizational skills.

8) Strong written skills.

9) Strong presentation skills.

MINIMUM EXPERIENCE:

1) At least 10 years of experience leading a multi-hospital system Regulatory and Accreditation program.

2) Experience leading interdisciplinary initiatives in process improvement and directly with improving reliability of healthcare delivery at the point of care.

REQUIRED CERTIFICATION:

1) Certified Joint Commission Professional (CJCP) or

2) Certified Professional Healthcare Quality (CPHQ) within twelve months of hire date

SKILLS, KNOWLEDGE AND ABILITIES:

1) Experienced with and practiced at performance improvement activities.

2) Skilled at developing and conducting educational presentations.

3) Expert at remediating findings when in a facility.

4) Adept at developing methods, tools, reports, data aggregation and conducting regulatory and operational surveys for Tenet facilities, including the review of regulatory requirements and accreditation standards and Conditions of Participation.

5) Prepares written reports of clinical and operational survey findings.

6) Make enhancements to survey standards, tools, forms and processes.

7) 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.

8) Expert on regulatory requirements and accreditation standards, preparation activities, and success with surveys.

9) Knowledgeable in the areas of peer review, risk management, patient safety, infection control prevention and reporting.

10) Proficient at detail oriented work and has ability to work with and analyze complex health care process and outcome data using both qualitative and quantitative techniques.

11) Polished communicator (written, verbal and presentation skills) with many levels of key stakeholders from the board level to the point of care staff.

12) Expert on TJC, Centers for Medicaid and Medicare, Quality Improvement Organization (QIO), state requirements and other regulatory standards / processes.

13) Expert with current trends in quality and other areas of responsibility as applicable.

14) 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.

15) Identifies potential or actual regulatory/accreditation risk issues at facilities in the assigned groups that can impact regulatory/accreditation compliance and pose a financial or reputational risk to the facility or company and immediately reports those findings to the Tenet Quality Management Department to address the issue.

TRAINING REQUIREMENTS

Individualized orientation and required annual updates to include use of Tenet computer software, data to be reported, role expectations, etc.

PRIMARY INFORMATION, TOOLS AND SYSTEMS USED

1) PC based Word and Excel spreadsheet programs

2) Industry publications as they relate to Quality and other areas, as applicable, such as Safety, Risk Management, etc.

a) Electronic Health Record

b) eSRM (Risk Management System)

c) Balanced Score Card / Clinical Operations Scorecard

d) SharePoint

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.