RN Director of Quality & Regulatory Compliance

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.

• Facilitates ongoing and special committees/task forces, providing consultative support to clinical committees, PI teams, and other departments related to quality, regulatory concerns, and policies/procedures.
• Serves as a resource for hospital departments regarding professional standards of practice and requirements of accreditation and regulatory agencies.
• Coordinates and directs activities, tracers, and education to prepare the organization to meet the requirements of Joint Commission, AHCA, and CMS. Communicates with courtesy and respect when interacting with internal or external customers, in person or on the telephone, maintaining a professional appearance and manner.
• Coordinates the improvement work of teams, oversees the execution of improvement plans, assists teams in using improvement tools, and evaluates team leadership on progress.
• Identifies deficient practice patterns, participates in Root Cause Analysis and FMEA teams, and provides recommendations for improvement and/or correction. Serves as a resource on regulatory issues to leaders, facilitating the education of staff about changes in regulations that impact care delivery or other work practices.
• If designated as the PSO Liaison, the incumbent will serve as the primary link between the assigned entity or entities, their affiliated providers, and one or more federally listed Patient Safety Organizations (PSOs), while ensuring compliance with the Patient Safety and Quality Improvement Act (PSQIA) by the assigned entity or entities and their staff.
• The PSO Liaison will accurately define, implement, manage, and document all Patient Safety Evaluation System (PSES) processes in compliance with privacy, confidentiality, and security requirements established by organizational policies and federal regulations, while keeping leadership informed of PSES status and the level of engagement with the PSO(s) to improve patient safety and quality across the assigned entity or entities.

• Excellent verbal and written communication skills as demonstrated by application resume, work history, and interview process. [Required]

• Ability to work independently or in a team environment. [Required]

• Good math skills with an ability to understand and work with spreadsheets. [Required]

• Ability to work with data that is of sensitive and confidential nature. [Required]

• Skilled in use of computer programs such as Microsoft Excel, PowerPoint, and Word, Trove or similar Database. Proficiency in database management and Electronic Medical Record navigation. [Required]

• Working knowledge of or ability to learn and work with appropriate Joint Commission standards and AHCA/CMS regulations and information. [Required]

• Good organizational skills, strong attention to detail, and ability and willingness to multitask. [Required]

• Education in Performance Improvement such as Team Leader, Facilitator experience, Malcolm Baldrige, and/or LEAN Six Sigma. [Required]

• Bachelor's [Required]

• Master's [Preferred]

• Bachelor's in Nursing [Preferred]

• in healthcare-related field

• 3+ in leadership role [Preferred]

• 1+ in human factor analysis [Preferred]

• 3+ in quality and regulatory reporting, performance improvement management, patient safety, and statistical data analysis [Required]

• 3+ in healthcare setting [Preferred]

• Certified Professional in Healthcare Quality (CPHQ) [Preferred] OR

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