The mission of the Tennessee Center for Patient Safety (TCPS) is to advance Tennessee hospitals' adoption of proven strategies that enhance the reliability, safety, and quality of care received by patients. The TCPS provides extensive education, resources, and direct support to hospitals to accomplish the mission of better outcomes for patients.
Serves as the chief quality officer for THA, providing leadership and strategic direction on all THA initiatives on quality, patient safety, and health equity.
Under the direction of the President, this position has administrative oversight and guides the development of THA's policies and positions on quality and related clinical issues and designs, directs, implements, and evaluates THA initiatives and programs on these issues.
Oversees the TCPS and the THA responsibilities for all federal, state, or privately funded grants, contracts, or programs for quality improvement.
Leads the TCPS team in supporting the THA member hospitals in improving the quality and safety of the care they deliver.
A key aspect of the position is working in partnership with physicians on safety and quality initiatives through the THA Chief Medical Officer (CMO) Society and other partnerships.
Responsible for the THA Quality Committee, the THA Council on Inclusion and Health Equity, and CMO Society.
Leads the TCPS team in assisting with legislative advocacy efforts and provides support to government affairs staff on clinical and workforce issues.
Creates value for THA membership by actively engaging members on relevant issues and their participation in both internal and external taskforces and committees, education programs, collaborative projects, networking, and recognition opportunities.
The ability to foster positive relationships and create collaborative partnerships is a primary responsibility of the position.
Represents THA and its quality and patient safety priorities as liaison to national and state regulatory agencies, such as the Centers for Medicare & Medicaid Services (CMS), The Joint Commission (JC), Tennessee Department of Health (TDH), and numerous other external stakeholder organizations.
Monitors state and national trends and issues related to clinical matters, quality, and patient safety and prioritizes and communicates emerging issues and recommendations to the THA Board, staff, and membership.
Has responsibility for development of corporate and department goals on quality, patient safety strategies, and related clinical issues and the development of programs, education, resources, and other operations to ensure effective accomplishment of THA goals.
Consults with THA staff and the membership to assure compliance with federal and state regulations, laws, and accreditation standards that impact hospital clinical operations.
Strives to meet the needs of hospitals on numerous complex quality and care-related issues and helps the membership proactively address emerging issues.
ESSENTIAL FUNCTIONS OF THE JOB:
1. The ability to adapt to a changing work environment and meet challenges presented throughout the day.
2. Determine the strategic plans for THA on quality, patient safety, and related clinical issues to proactively position the association and membership for emerging issues.
3. Build and maintain a strong leadership persona with key parties essential to the work of THA, the board, staff, stakeholders, and members.
4. Develop THA's policies and positions on quality and safety and related clinical issues and present recommendations to THA leadership and the governing Board.
5. Assist in providing analysis of proposed legislation and rules that impact hospital quality reporting, operations, or related financial impact. Oversee all activities of TCPS, including prioritizing programs and initiatives to meet strategic goals.
6. Develop, implement, and evaluate THA quality improvement activities and guide and oversee the development and implementation of comparative clinical databases.
7. Develop and foster partnerships with physicians and surgeons to support quality and patient safety improvement initiatives. Support the CMO society and engage them in THA quality initiatives.
8. Provide oversight and leadership for the TCPS Patient Safety Organization (PSO) program and support staff in marketing and implementing the program.
9. Foster strategic partnerships and collaborations with the TDH, affiliate organizations, and external stakeholders.
10. Evaluate funding opportunities to assist THA and hospital members with quality improvement efforts.
11. Lead the THA Quality Committee that is responsible for making policy and priority recommendations to the THA Board on clinical quality, patient safety, and public reporting.
12. Lead THA's health equity programs to support hospitals in providing high-quality equitable care to their communities.
13. Lead the THA Council on Inclusion and Health Equity, which provides input on THA's health equity programs and strategies and the Agenda 21 Internship Program.
14. Oversee the development of education programs, website, and other resources on quality, patient safety, and other clinical needs to support THA member hospitals.
15. Lead the TCPS team in providing written responses and commentary to state and federal regulatory agencies, JC, CMS, and others on proposed rules and standards, public reporting, and payment systems tied to quality performance.
16. Provide support to THA on clinical issues, accreditation standards, and regulatory requirements of healthcare professionals.
17. Assist in THA advocacy and legislative activities related to nursing, workforce, and clinical issues by providing testimony or written comments as needed.
18. Advocate for members and serve as a liaison to the TDH on regulatory issues.
19. Monitor state and national issues and trends regarding clinical issues, such as JC, workforce shortages, nurse staffing and outcomes, patient safety, etc.
20. Maintain an up-to-date knowledge of hospital licensure and JC accreditation standards.
21. Handle or oversee special assignments by the President and the COO.
22. Must be available for out-of-town travel approximately 10 percent of the time, be able to drive an automobile, and maintain a valid driver's license.
23. Must be available in the office during regular office hours unless a hybrid arrangement is in place or job responsibilities require otherwise.
Expected Outcomes and Results:
1. Participation of THA member hospitals in data collection and reporting on quality and patient safety measures and improvement programs offered through the association.
2. Development of strategic partnerships with the TDH and other partner organizations to assist hospitals in improvement efforts.
3. Implementation of priority quality and safety initiatives through the TCPS, focusing on leadership development and engagement, reduction in hospital acquired conditions and healthcare associated infections, and readmissions.
4. Implementation of collaborative initiatives to share best practices and expertise.
5. Provide conferences/workshops, education programs, and technical assistance to members on quality and patient safety.
6. Regular reports are provided to hospital leaders to keep up to date on performance on priority measures.
7. Report to the THA Board on progress toward quality improvement and make recommendations to advance quality, safety, and equity.
8. TCPS goals and objectives are met as outlined in program grants and contracts.
9. Networking and collaborative opportunities are created among hospitals to improve care.
10. TCPS staff are recognized as experts in supporting hospitals.
11. Participation in the TCPS PSO program to support voluntary reporting of medical adverse events, sharing and learning for aggregated findings, and dissemination of best practices.
12. Positive relationships with internal departments, external agencies, and government entities.
13. Support staff in funding, programmatic design, and implementation of quality improvement projects specific to the needs of critical access hospitals.
Dollar value: Total budget for department and programs, including grants, ranges from $850,000 to $2.5 million.
Volume: 139 Member hospitals
Number of people supervised: The department consists of 8 positions, including the Sr. VP. The number of direct reports may vary depending on the background of the selected applicant.
ORGANIZATIONAL STRUCTURE: All departmental positions (excluding the Sr. VP) are listed below. Organizational structure, including which positions report directly to the Sr. VP will be determined based on the background of the selected applicant.
Vice President for Operations—Responsible for oversight of TCPS operations to meet department goals, ensure compliance with meeting grant objectives, budgets, and related deadlines.
PSO Director—Responsible for the daily operations of the THA PSO and compliance with the Agency for Healthcare Research and Quality (AHRQ) certification regulations.
Clinical Quality Improvement Specialist—Registered nurse responsible for direct support of hospitals in implementing improvement initiatives and related grants.
Infection Preventionist—Responsible for direct support of hospitals in reducing hospital-associated infections and emerging pathogens.
Program Manager—Responsible for supporting the Agenda 21 minority internship program and the daily management of the PSO program and Tennessee Surgical Quality Collaborative (TSQC) with clinical leaders.
Clinical Quality Data Manager—Responsible for quality data collection, analysis and reporting for the department in support of priority programs and initiatives.
Communications Coordinator and Executive Assistant—Responsible for supporting team members in executing strategic initiatives and projects through logistics support and communications with members.
GUIDANCE & DIRECTION: (Policies, precedents or procedures that guide this work)
The THA Quality Committee makes recommendations on policies and association positions and prioritizes programs for development, which are then presented to the THA President and Board for approval.
Educational and Experience Requirements Needed to Perform the Duties of the Job:
1. Nursing degree or master's degree in another field with demonstrated experience in quality improvement and leadership.
2. Minimum of five years' experience operating a quality and patient safety program in a hospital, health system, or hospital association.
Licensing or Other Special Certifications Required:
Registered nurse license preferred, unless candidate has at least five years of direct experience in operating a hospital or association patient safety program.
Skills Required to Perform the Duties of the Job:
1. Knowledge of quality improvement, patient safety principles and strategies, healthcare, and delivery systems.
2. The ability to publicly speak and articulate clearly and concisely.
3. The ability to view the big picture of healthcare.
4. The ability to assess complex issues, manage multiple obligations, prioritize, and develop straightforward initiatives.
5. Organizational and planning skills to develop initiatives and programs to meet determined needs.
6. Leadership skills to determine strategic direction.
7. Leadership skills for coalition building.
8. The ability to teach, supervise, and consult.
9. Knowledge of performance improvement models, statistics, and interpretation of data.
10. Knowledge of hospital operational requirements, including licensure standards, accreditation requirements, and other statutes and regulations.
11. Ability to relate to various groups and individuals on a variety of issues with respect for diverse viewpoints.
12. Ability to write, edit, and design.
13. Working knowledge of the legislative process.
14. Working knowledge of the JC and the TDH.
15. Must have a working knowledge of Microsoft Office Products.