In association with the Director, Quality and Patient Safety, and according to established policies and procedures, manages regulatory compliance and improvement at assigned hospital site(s). Responsible for on-going hospital readiness for accreditation. Collaborates to identify regulatory compliance improvement opportunities/priorities, develop regulatory compliance plans and follow through on implementation of plans to ensure accreditation and regulatory requirements are met. In collaboration with system regulatory leadership ensures audits and action plans, recommendations for improvement and updates are provided to regulatory governing bodies as deemed. Provides leadership and education to departments regarding regulatory compliance, process/performance measurements, monitoring and evaluation. Collaborates with Occupational Health Services on a variety of functions including recommended immunizations and policies and procedures related to regulator mandates and infection control. Develops, monitors and revises functional processes in accordance with goals and objectives. Develops current to intermediate goals and measures for the department. Measures and assesses performance. Monitors activities for and ensures compliance with laws and government regulations. Responsible for DMC and Tenet policies, as well as JC (Joint Commission) coordination and follow-up. As directed, implements external and internal audit recommendations. Ensures hospital departments achieve objectives for diversity of their suppliers.
1. Bachelor's degree in Public Health, Health Care Administration, Operations Analysis, clinical or other related field, or the equivalent combination of education and/or experience. Master's degree in a related field preferred.
2. Three years of progressively more responsible related experience in an acute care facility including direct involvement with senior management, physicians and outside entities regarding compliance or other impactful issues.
3. Licensed to practice as a Registered Nurse in the State of Michigan preferred.
4. Experience in the use of personal computers as well as knowledge of statistical or spreadsheet software tools.
1. Analytical ability to serve in an advisory/consultative role in determining and/or developing strategies, policies, processes, protocols and methods, frequently in the absence of guidelines or technical assistance, and to evaluate and direct complex systems that foster innovative approaches to procedures/processes on a system-wide basis.
2. Communication and interpersonal skills for frequent contact with internal customers as well as stakeholders external to the DMC to persuade or negotiate on a wide range of subjects in situations which may be controversial, sensitive and/or lead to confrontation. A mastery of a variety of communication modalities is required to include leading meetings, making formal presentations, and writing complex documents and managing complex relationships over time.
3. Project management skills including the ability to define program, project, or process objectives, identify stakeholders and their interests, plan steps, coordinate and allocate human, technological and fiscal resources to accomplish goals and objectives in a resourceful yet timely manner.
4. Leadership skills including demonstrated willingness to pursue leadership roles with increasing levels of accountability, comfort with decision-making responsibilities, coaching, teaching and counseling skills, and the ability to inspire and build confidence in others and to forge alliances and garner support.
5. Technical knowledge of regulatory standards and performance improvement principles.
6. Knowledge of word processing/spreadsheet applications and database management systems.
Employment practices will not be influenced or affected by an applicantâ��s or employeeâ��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.
Internal Number: 2105013798
About DMC Harper University/Hutzel Women's Hospital
Tenet Healthcare Corporation (NYSE: THC) is a diversified healthcare services company headquartered in Dallas with 112,000 employees. Through an expansive care network that includes United Surgical Partners International, we operate 65 hospitals and approximately 510 other healthcare facilities, including surgical hospitals, ambulatory surgery centers, urgent care and imaging centers and other care sites and clinics. We also operate Conifer Health Solutions, which provides revenue cycle management and value-based care services to hospitals, health systems, physician practices, employers and other clients. Across the Tenet enterprise, we are united by our mission to deliver quality, compassionate care in the communities we serve.