TRA USPI Interim Quality Director

About the Company

We are a community built on care, extending compassion to those in need to improve health and well-being. Starting as a small operation in California in 1969, we have grown into a leading health system with 65 hospitals and approximately 510 outpatient centers. Our operations include three businesses: hospitals and physicians, USPI, and Conifer Health Solutions. We are dedicated to excellence, innovation, and patient-centered care, shaping a business that meets community needs.

About the Role

The Patient Safety Director will serve as the functional domain thought leader for safety at Tenet, collaborating with other functional leaders (e.g., Safety, Regulatory, Infection Prevention) to build an integrated plan for impact. This role is responsible for developing a safety agenda that bridges across Tenet’s three business units (Acute Care Hospitals, USPI, and TPR) and supports the development of Patient Safety Officers (PSOs) at the facilities. The position ensures adherence to Patient Safety Regulations & Accreditation and drives safety outcomes Tenet-wide while up-skilling PSOs.

Key responsibilities include:

• Developing a safety agenda that addresses performance opportunities, incorporates proven practices, and is distilled for clarity in implementation, training, tracking, and goal-setting.
• Collaborating with peer knowledge domain leaders to build an integrated "quality-safety-regulatory-infection prevention" plan that overlaps domains while maintaining clarity of purpose.
• Implementing processes that drive outcomes-based, evidence-based, and cost-effective safe practices across multiple facilities (e.g., ACH, USPI, and TPR).
• Serving as a higher-level expert in safety practices and goal formulation for facility leaders.
• Supporting multiple facilities with advice, best practice tools, templates, and knowledge-sharing opportunities.
• Collaborating with facility leadership (CEO, CNO, COO, CMO, PSOs, and DCQIs) to adhere to federal, state, and local regulations, including The Joint Commission, EMTALA, and FDA reporting.

Responsibilities

• Provide oversight to Patient Safety Officers in executing all domains of practice, including claims and litigations, event reporting system management, case investigations, event reviews, risk financing, device failure management, legal and regulatory compliance, grievances, patient safety operations, standard work initiatives, proactive risk assessment, and ethical issue consultation.
• Support processes for managing post-event diagnostics, adverse event disclosure, and shared learning to prevent recurring events.
• Verify adherence to the Tenet Operating System for Patient Safety, including managing the Patient Safety Reporting System (PSRS) and reporting.
• Support facilities in developing sentinel event corrective action plans and follow-up on measures of success within specified timeframes.
• Assist Patient Safety Officers in executing robust process improvement and auditing/monitoring processes.
• Verify that facilities have an ethics committee structure with guidelines for handling bio-ethical issues.
• Ensure Tenet Standard Work initiatives are in place and supported by robust process improvement plans.
• Verify facility preparedness for surveys (e.g., State, TJC, CMS) in collaboration with the Tenet Quality and Patient Safety Department.
• Support regulatory and accreditation quality managers during informal and formal facility reviews on identified issues.
• Collaborate with quality managers to assess the progression and sustainment of regulatory and accreditation strategies.
• Support the development and use of Tenet methods, tools, and resources for regulatory and accreditation preparedness and sustainment.
• Assist in the implementation and sustainment of successful regulatory and accreditation preparation and surveys.
• Support facilities in formulating responses (plans of correction) to regulatory and accrediting organizations and third-party payers.
• Collaborate with quality managers to assess adherence and sustainment of corrective action plans.
• Support the Tenet Quality and Patient Safety Department’s balanced scorecard/clinical service scorecard and facility goals, including participation in publicly reported data (e.g., Leapfrog, AHRQ survey).
• Routinely visit facilities to review quality, safety, service, and regulatory items.
• Support the implementation and sustainment of clinical process improvements through analysis and summarization of reports.
• Monitor facilities’ progress with safety action plans (e.g., AHRQ, SREs, FMEA status) and regulatory action plan follow-up.
• Monitor and address the need for intervention or escalate to appropriate personnel based on measure performance.
• Verify that facilities have a process in place to adhere to Operative and Invasive Policy and Procedures.

Qualifications

• Registered Nurse (RN) with a BSN degree required; advanced degree in a health-related field (Master’s or Doctorate) preferred.
• Current nursing licensure.
• At least five years of experience in quality/performance improvement and/or patient safety.
• At least five years of experience leading interdisciplinary initiatives in process improvement or improving healthcare delivery reliability at the point of care.
• Preferred certifications: Certified Professional Healthcare Quality (CPHQ), Certified Joint Commission Professional (CJCP), or Certified Professional Healthcare Risk Management (CPHRM).

Subordinates

This role supervises approximately 2 direct reports and 30-40 indirect reports.