Director Quality and Accreditation at AdventHealth

Date Posted: 5/20/2020

Job Snapshot

  • Job Schedule
  • Location:
    Mansfield, TX
  • Job Category
  • Date Posted:
  • Job ID:
  • Job Family
    Quality/Clinical Effectiveness
  • Travel
  • Shift
    1 - Day
  • Organization
    Texas Health Huguley Hospital

Job Description


Director of Quality and Accreditation -  Texas Health Mansfield- operated as joint venture between Texas Health Resources and AdventHealth

Location: 2300 Lone Star Road; Mansfield, TX

Top Reasons to Work at Texas Health Mansfield; Mansfield, TX 

•         Join a family of caregivers focused on whole-person health and committed to making communities healthier.

•         Provide wholistic care for patients that extends to the spiritual level by praying with patients and families.  Chaplains are available to meet with patients, families and team members 24 hours a day, 7 days a week to provide spiritual support.

•         Help develop a brand new $150 million community hospital and medical office building that will provide services such as Medical/Surgical, ICU, Women’s Services, General Surgery, Orthopedics, Interventional Cardiology and Gastroenterology.

•         Grow in your career with AdventHealth, named in 2018 by Becker’s Hospital Review as one of the “150 Top Places to Work in Healthcare”.  AdventHealth has partnered with Texas Health Resources, named in 2019 as one of Fortune’s 100 Best Companies to Work For, to build Texas Health Mansfield, which is creating new opportunities for employment and professional growth. 

•         Thrive in the Mansfield community, ranked by CNN/Money Magazine as #17 for “Best Places to Live”.  Mansfield is one of the fastest growing areas of North Texas, projected to reach more than 250,000 residents by 2023.  Future job growth over the next ten years is predicted to be 41%, higher than the national average of 33.5%.  Mansfield has top-rated schools, over 900 acres of parkland, quality housing, a historic downtown area, recreational opportunities for all ages, and a growing business community.

Work Hours/Shift:

Full Time

You Will Be Responsible For:

•         Responsible for developing and implementing an organization-wide quality assurance / performance improvement program 

•         Coordinates monthly Quality Management Council and ensures timely reporting of key quality metrics

•         Prepares quarterly board reports and annual summary

•         Maintains current knowledge of State, CMS, Joint Commission and other regulatory standards and assesses facility compliance

•         Serves as Joint Commission liaison and ensures timely completion of survey applications

•         Serves as primary survey coordinator for all accreditation visits

•         Oversees all post-accreditation activities and any follow up action plans

•         Perform chart audits for key focus areas

•         Oversees and works collaboratively with Risk Management to facilitate external peer reviews

•         Directly supervises Quality/Accreditation/Risk Management/Patient Safety/Infection Prevention departments.  Is responsible for the overall direction, coordination and evaluation of the units and employees.

•         Carries out supervisory responsibilities in accordance with the organization’s policies and applicable laws.  In conducting these activities, the Quality / Accreditation Director will exercise independent judgement and discretion in the interest of Texas Health Hospital Mansfield.  Responsibilities include:  interviewing, hiring and training employees: planning, assigning and directing work; appraising performance; rewarding and disciplining employees; addressing complaints and resolving problems; effectively conducts counselling, disciplinary and termination sessions as needed, utilizing organizational and management skills;  analyzes performance and prepares evaluations and effectively conducts annual performance reviews for subordinates in accordance with organizational policy and procedure


What will you need:        

  • Requires critical thinking skills, decisive judgment and the ability to work with minimal supervision
  • Must be able to work in a stressful environment and take appropriate action
  • Current unrestricted state of Texas RN license
  • Bachelor’s Degree in Nursing
  • Three years’ experience in quality management, quality measures, accreditation, acute care regulation, and patient safety initiatives
  • Working knowledge in the concepts associated with performance improvement
  • Previous experience with Medicare and Joint Commission surveys needed
  • Master’s Degree in Nursing or related healthcare field preferred
  • Certified Professional Healthcare Quality (CPHQ) highly preferred


Job Summary:

Responsible to oversee the development and implementation of an organization-wide Quality Assurance / Performance Improvement Plan which includes outpatient services, along with patient safety and infection control regulations. Work collaboratively with all departments to ensure safe, effective and reliable service.  Responsible for all aspect of accreditation including application, survey readiness, survey follow up activities. Oversee hospital performance related to value-based-purchasing and identify opportunities for improvement.  Must maintain current knowledge of Medicare’s Condition of Participation, The Joint Commission Standards for Hospital Accreditation, and Texas State regulations.



This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances.

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