Director Quality and Regulatory Compliance Heart of Florida FT at AdventHealth

Date Posted: 10/5/2021

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Job Snapshot

  • Job Schedule
    Full-Time
  • Location:
    Davenport, FL
  • Date Posted:
    10/5/2021
  • Job ID:
    21025088
  • Job Family
    Quality/Clinical Effectiveness
  • Shift
    1 - Day

Job Description


Description

YOU MUST ATTACH RESUME, DEGREES, CERTIFICATIONS AND/OR LICENSES WITH APPLICATION

Director Quality & Reg Compliance Heart of Florida

Location Address: 40101 US-27, Davenport, FL

Top Reasons to Work at AdventHealth Heart of Florida

  • Close proximity to Walt Disney World
  • Various outdoor activities for families and children to enjoy
  • Beautiful local golf courses available year round
  • Faith-based work environment
  • Great benefits 

GENERAL SUMMARY:

Under the general direction of the Executive Director Quality and in conjunction with the Medical Staff and Administration, facilitates, organizes, implements and evaluates a system to monitor quality initiatives to meet the goals of AdventHealth Heart of Florida and AdventHealth Lake Wales, as well as licensed off-sites for benchmarking performance in patient outcomes and cost-effective healthcare.  This role is responsible for meeting requirements for entities such as The Joint Commission, Centers for Medicare and Medicaid Services, Centers for Disease Control and other applicable Federal, State and local regulatory/or accrediting agencies.

PRINCIPAL DUTIES AND JOB RESPONSIBILITIES:

All essential functions must be performed. Reasonable accommodations may be made to enable individuals with qualified disabilities to perform the essential functions.

  • Manages and facilitates direction of processes related to the following: Quality and Regulatory Compliance; Inpatient Quality Reporting (IQR) measures; Outpatient Quality Reporting (OQR) measures etc., Culture of Safety Survey, The Joint Commission, and the National Healthcare Safety Network.
  • Serves as a primary contact for quality reporting such as:  Press Ganey; Premier; Centers for Disease Control; The Joint Commission; Safe and Reliable Care; Center for Medicare and Medicaid Services and other partners in improvement and accreditation activities.
  • Works closely with senior level leadership to prepare presentations and/or case reviews for the Medical Staff Triage, Medical Staff Quality Committee, and the Quality Council of the Board. 
  • In collaboration with leadership, acts as internal consultant to the Medical Staff, Administration, all Clinical and Ancillary Departments regarding accreditation and regulatory compliance issues, as well as quality improvement processes.
  • Manages and facilitates direction of analysis and interpretation of quality related trended data and partners with unit and department leaders to develop plans to improve.
  • Manages, coordinates and facilitates The Joint Commission (TJC) applications, surveys, preparation, and follow-up activities.
  • Performs the TJC Focused Survey Assessment (FSA) annually and manages the improvement activities identified through the assessment.
  • Provides orientation and ongoing education for employees, medical staff, volunteers and other partners on performance improvement and patient safety.
  • Works in collaboration with the following teams impacting quality and safety reporting such as,  Coding, Clinical Informatics and Clinical Documentation Improvement.
  • Works in collaboration with Risk Management to develop and implement plans that supports patient safety initiatives.
  • Facilitates inter/intradepartmental participation in quality improvement teams.
  • Oversees ongoing revisions, as necessary of the Performance Improvement/Patient Safety, and Infection Control plans.
  • Collaborates with the Medical Staffing Office to recommend and provide quality data analysis for Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE) for TJC standard mandating detailed evaluation of practitioners ‘professional performance.
  • Participates in accomplishing the Clinical Performance Improvement initiatives and Corporate Clinical Accountabilities identified by the organization.
  • Participates in Performance Improvement team formation, facilitation and validation of metric reporting, to ensure ongoing PI efforts are “hard wired”/standardized.
  • Collaborates with Risk Management to support root-cause analysis in conjunction with clinicians as requested.
  • Serves as liaison to hospital departments to support their quality initiatives through database design and statistical analysis.
  • Uses available resources to provide guidance in Quality and Performance Improvement initiatives to Medical Staff, Administration, all Clinical and Ancillary Departments.
  • Utilizes clinical information systems to provide outcomes management data to support the overall quality program.
  • Manages and facilitates direction of the Clinical Resources (Quality) department effectively and efficiently.
  • Communicates information from management meetings to staff.
  • Provides recommendations to modify and/or improve processes/flow of Department.
  • Serves on various patient safety, performance, regulatory and accreditation committees.
  • Pursues educational opportunities for Professional growth.
  • Other duties as assigned.
Qualifications

What you will need:

KNOWLEDGE AND SKILLS REQUIRED:

  • A minimum of three (3) years in Quality reporting and Performance Improvement Management.
  • Computer literate and proficient in – database management, Electronic Medical Record navigation
  • Education in Performance Improvement such as Team Leader, Facilitator experience, Malcolm Baldrige and/or LEAN Six Sigma.
  • Excellent Communication/Motivational skills.
  • Experience in Quality and Regulatory reporting; Patient Safety; Performance Improvement and Statistical Data Analysis

KNOWLEDGE AND SKILLS PREFERRED:

    • Experience in Human Factor Analysis

EDUCATION AND EXPERIENCE REQUIRED:

  • Bachelor of Science 3+ years’ experience

EDUCATION AND EXPERIENCE PREFERRED:

    • Master’s Degree in related healthcare or business field

LICENSURE, CERTIFICATION OR REGISTRATION PREFERRED:

 Certification in Healthcare Quality (CPHQ)

  • Certification in Healthcare Accreditation
  • Certification in Patient Safety
  • Certification in Infection Control

LIVING OUR SERVICE STANDARDS

How we treat those we serve and each other is what sets us apart from other healthcare organizations. We want everyone who walks through our doors to feel loved, cared for, and at ease.  Whether you are clinical or non-clinical, your actions and behaviors can create an environment that either builds trust or causes anxiety and fear. We have made it easy for you to ensure that you are always building trust and providing excellent care by exhibiting our Service Standards. 

All team members will be held accountable for consistently living out our 16 Service Standards and the additional behaviors listed below to ensure that every person, every time has an exceptional experience.

KEEP ME SAFE

I make safety my number one priority.

I protect privacy and confidentiality.

I keep my environment clean.

I follow the dress code and wear my badge correctly.

LOVE ME

I treat others with uncommon compassion.

I nurture whole-person care through CREATION Health.

I treat others with fairness and respect.

I listen and communicate using iCARE. (Introduce, Connect, Anticipate, Reinforce, Extend)

MAKE IT EASY

I help guests to their destination.

I speak highly of others to provide connected care.

I collaborate to create solutions, not excuses.

I innovate and continually seek ways to improve our work.

OWN IT

I am positive and aim to exceed all expectations.

I follow through on commitments.

I use discretion with personal devices.

I recover service and restore trust using ACT. (Acknowledge/Apologize, Correct, Thank)

Team members must conform to all AdventHealth organizational and departmental policies and procedures including but not limited to:

  • Mission
  • Vision
  • Values
  • Code of Conduct as outlined in the “Guidelines for Employees” handbook

Establishes and maintains a history of regular attendance; makes appropriate use of PDO and observes department call-in procedures for absence; establishes and maintains punctual work habits. Exhibits timely arrival and departure and dependable time habits including meal and other breaks.

Attends and participates in mandatory facility-wide and department training/meetings as required (including but not limited to:  ALN, safety training, etc.). Is able to demonstrate and apply knowledge of fire, safety, security, and disaster procedure regulations as presented in orientation, outlined in the safety manual, and as pertains to each work area.

Required to respond to emergency situations (i.e. disasters, hurricanes, etc.) by reporting to department and staying until the crisis is over or your position is covered by incoming personnel. This is a mandatory requirement. Refusal to respond may result in termination.

Contributes to the successful achievement of department-stated goals and objectives and will facilitate staff cohesiveness and communication.


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

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