Address
Form of workAll the benefits and perks you need for you and your family:
- Benefits and Paid Days Off from Day One
- Student Loan Repayment Program
- Career Development
- Whole Person Wellbeing Resources
- Mental Health Resources and Support
- Debt-free Education* (Certifications and Degrees without out-of-pocket tuition expense)
Our promise to you:
Joining AdventHealth is about being part of something bigger. It's about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind, and spirit. AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding that together we are even better.
Schedule: Full-Time
Shift: Days
The community you'll be caring for: AdventHealth Waterman - 1000 WATERMAN WAY, Tavares, 32778
The role you'll contribute:
The Manager provides leadership, direction, and support for Florida Hospital
Waterman's Regulatory Readiness and Quality Improvement Projects for continuous
improvement in safety culture and compliance. This responsibility includes providing.
planned, systemic approach to identifying, designing, measuring and monitoring all
Quality Improvement activities. The scope of work includes education, training, hands.
on participation, leadership, auditing, and continuous evaluation of patient safety data
and compliance with standards.
The value you'll bring to the team:
Provides oversight of Quality Improvement Projects
Serve as expert resource on accreditation and regulatory issues to staff and physicians.
Provides coordination to ensure services are provided in accordance with accreditation standards and Medicare Conditions of Participation
Coordinates performance of validation tracers and audit activity to evaluate status of Regulatory Readiness.
Provides feedback to leadership on results of tracer/audit activity.
Participates in -multi-disciplinary tracer committee.
Identify areas of vulnerability related to accreditation standards and regulations.
Responsible for tracking action plans necessary to close gaps in meeting standards/requirements.
Monitors and assures direct data analysis, trends, and reviews are completed timely.
Coordinates the hospital review and accreditation programs to ensure requirements are met.
Chairs the Regulatory Readiness Committee
Collaborate with other hospital departments to support quality initiatives and Regulatory Readiness.
Identify and share with leadership trends and opportunities for improvement in patient safety.
Communicates to administration regarding Regulatory Readiness and progress if quality initiatives.
Adhere to requirements and deadlines for reporting.
Ensures the timely submission of accurate data to comparative databases to accomplish effective benchmarking and meet regulatory requirements.
Facilitates use of data to identify opportunities to improve clinical outcomes, prevent events with the potential to negatively impact patient care, promote a culture of patient safety and improve hospital processes.
Shares new information or changes in regulatory standards with appropriate leaders.
Provides training to departments in process improvement concepts and tools as needed.
Serves as a resource to physicians regarding metrics and outcomes.
Ensure results of physician metrics are compiled timely as requested.
Act as a liaison to Medical Staff to support quality initiatives.
Facilitates inter/intra departmental participation in Quality Improvement utilizing lean tools and techniques, PDSA, change management approaches and human factor re-engineering.
Ensure all new employees are oriented to patient safety and infection prevention programs to heighten awareness and importance.
Facilitates completion of annual patient safety culture survey
Work with other departments to gather data for completion of leapfrog survey
Completes and submits leapfrog survey timely.
Works with policy committee to keep policies and procedures current and uploaded to the intranet.
Participates in communication with other AHS facilities regarding regulatory compliance and Improvement Projects.
Participates in applicable meetings and calls with Central Division North Region
Completes evaluations of direct reports timely
Participates in interview and hiring process for open positions in Quality as needed.
Performs other related duties as assigned.
The expertise and experiences you'll need to succeed:
REQUIRED:
BS degree or equivalent in Business, Healthcare Administration, Finance, Nursing or Clinical Operations. Experience in a healthcare environment an advantage
Certified in CPHQ or HCQM highly desired or other equivalent certification.
Minimum of 3 years' experience in Quality or Performance Improvement
Experience in organizing and leading improvement teams
Experience in coordinating the accreditation activities for a successful review
Completed or working toward HCQM or CPHQ certification.
Working knowledge of Lean, Six Sigma, PDSA and other process improvement methodologies and tools
Skilled in presenting and leading successful group discussion
Experience in interpretation of raw data and comparative analysis
Exceptional communication skills including the ability to influence in a collaborative manner.
Knowledge of regulatory requirements
Understanding of healthcare and QI principles required
Proficient computer skills and analysis of data
Understanding of healthcare systems and processes
Exceptional communication skills including the ability to influence in a collaborative manner.
PREFERRED:
HCQM certification
Six Sigma training
Experience in Leapfrog survey process
Understanding of CMS star rating
