Senior Director, Quality Management - Corporate Headquarters, Dallas, TX
Company: National Medical Association
Posted on: May 17, 2022
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 company--------s strategy related to regulatory
- 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
- 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
- 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
- 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
- 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
- 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
- Train, develop, motivate, and counsel direct reports to improve
their present performance and to prepare them for higher-level
- Communicate to all individuals and/or departments involved any
developments or information necessary for them to fulfill their
- 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
- Periodically review the human resource needs of the
organizational unit and recommend increases and decreases in
- 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
- 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
- Prepares reports and presents to various audiences using
statistical process control. PRIMARY INFORMATION, TOOLS AND SYSTEMS
- 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
- AMP with Tracers Qualifications: REQUIRED SKILLS: REQUIRED
KNOWLEDGE AND EXPERIENCE:
- RN degree preferred. Master--------s degree in healthcare
related field required
- Active RN professional license or other professional license if
- 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
- 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
- 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.
Job: Executive Search Primary Location: Dallas, Texas Facility:
Tenet Executive Search Job Type: Full-time Shift Type: Days
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
Keywords: National Medical Association, Dallas , Senior Director, Quality Management - Corporate Headquarters, Dallas, TX, Executive , Dallas, Texas
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