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.
All the benefits and perks you need for you and your family:
Benefits from Day One
Paid Days Off from Day One
Student Loan Repayment Program
Whole Person Wellbeing Resources
Schedule: Full Time - salaried position.
The community you’ll be caring for:
Faith Based & Mission driven Facility
Largest Employer in the County
Surrounded by beautiful Lakes, Golf Courses and Florida’s oldest State Park
Close knit community with a home town family feel
2 hours to just about any beach on either Coast
The role you’ll contribute:
The Accreditation/ Performance Improvement Specialist serves as a member of the Quality Department. This position leads regulatory survey readiness program planning for AdventHealth Lake Placid, Sebring, and AdventHealth Wauchula. This position coordinates survey activities, i.e. The Joint Commission (TJC), Agency for Health Care Administration (AHCA), and CMS Validation Surveys. This position is also responsible for managing selected Performance Improvement Initiatives within the facility. This individual proceeds on their own initiative in compliance with policies and procedures prescribed by the Quality Department leadership.
The value you’ll bring to the team:
Provides direction to department and facility leadership in planning of a systematic, organization- wide approach to continuous regulatory readiness
Chairs the Continuous Survey Readiness Committee
Communicates relevant changes to standards
Prepares reports and/or presentations
Coordinates educational materials/ presentations for committee members
Coordinates the planning and execution of the TJC intra-cycle monitoring (ICM)
Conducts tracer activity within the hospital and the clinic setting
Performs chart abstractions, audits, and documentation reviews to identify compliance with regulatory bodies.
Interviews staff through the tracer methodology process
Prepares summaries of gathered information
Participates in EOC rounds
Plans, develops, and conducts educational programs on accreditation for employees
Facilitates mock surveys and assists in the development of plans for improvement
Prepares survey specific documentation as requested by regulatory agencies
Participates in on-site surveys, including coordination of agendas, coordination of scribes, communication with surveyors and on-site staff, and communication of preliminary findings
Facilitates the development of corrective action plans as part of post-survey activities
Collaborate with all members of the healthcare team
Maintains knowledge in regulatory compliance
Conducts Failure Mode Effect Analysis (FMEA) as indicated/ required by regulatory entities and in accordance with the Patient Safety Plan
Attends and provides support for multiple hospital committees, such as UR/Performance Improvement/Patient Safety, Glycemic Management, Water Management, Environment of Care, Emergency Management, etc.
The expertise and experiences you’ll need to succeed:
KNOWLEDGE AND SKILLS REQUIRED:
Strong organization skills, including completing work by established deadlines.
Ability to evaluate and correlate clinical information with appropriate criteria and is able to utilize available computer hardware and software.
Skills to develop and engage in educational activities to facilitate learners’ achievement of specific objectives.
EDUCATION AND EXPERIENCE REQUIRED:
Associates Degree in Nursing or healthcare-related field.
Minimum 3 years as acute care nurse
EDUCATION AND EXPERIENCE PREFERRED:
Bachelor's or master’s degree preferred.
Minimum 1-year experience with teaching and/or leading evidence-based project preferred.
LICENSURE, CERTIFICATION OR REGISTRATION REQUIRED:
Registered Nurse with current licensure to practice in the State of Florida required.
LICENSURE, CERTIFICATION OR REGISTRATION PREFERRED:
CPHQ or other Healthcare Quality or Safety-related certification preferred.
At AdventHealth, Extending the Healing Ministry of Christ is our mission. It calls us to be His hands and feet in helping people feel whole. Our story is one of hope — one that strives to heal and restore the body, mind and spirit. Our more than 80,000 skilled and compassionate caregivers in hospitals, physician practices, outpatient clinics, urgent care centers, skilled nursing facilities, home health agencies and hospice centers are committed to providing individualized, wholistic care.