Audit/Accreditation Manager – Quality/Safety – Orlando at AdventHealth

Date Posted: 7/25/2019

Job Snapshot

Job Description



Audit/Accreditation Manager – Quality/Safety – Orlando

AdventHealth Orlando seeks to hire a Audit/Accreditation Manager who will embrace our mission to extend the healing ministry of Christ.



Facility Profile:

Located on a lush tropical campus, our flagship hospital, 1,368-bed AdventHealth Orlando, serves as the major tertiary facility for much of the Southeast, the Caribbean and South America. AdventHealth Orlando houses one of the largest Emergency Departments and largest cardiac catheterization labs in the country. We are already one of the busiest hospitals in the nation, providing service excellence to more than 32,000 inpatients and 125,000 outpatients each year.



Work Hours/Shifts:

M – F ; 8a-5p



Job Summary:

The Manager of Audit/Accreditation ensures organizational strategy around Quality and Safety is translated and executed to ensure a culture of safety and quality as an organization-wide imperative in both in-patient and out-patient environments. The Manager is responsible for facilitating the deployment and continuous improvement of an Internal Audit/Tracer program. This program will objectively evaluate systems, processes and functions across the organization to ensure their effectiveness and adherence to standards. Standards to which these activities must adhere may include policies, regulations, nationally-recognized guidelines or other criteria adopted by AdventHealth senior leadership. The Manager is also the expert in all accreditation and ISO -9001 standards for the organization. They provide standards interpretation for the organization at all levels. Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all.



Knowledge, Skills, Education, & Experience Required:

  • Strong organization skills
  • Excellent analytical and problem-solving skills
  • Effective oral and written communication skills, with the ability to articulate complex information in understandable terms to all levels of staff
  • Effective computer skills, particularly Microsoft Office Outlook, Word, Excel
  • Ability to work in a matrix-management environment to achieve organizational goals Knowledge and application of audit principles in a healthcare environment.
  • Expert knowledge of accreditation requirements (DNV, Joint Commission), regulations and guidelines.
  • Initiative and ability to work independently (self-direction), while thriving in a setting requiring collaboration and teamwork for maximal efficiency and effectiveness. Attention to detail that ensures follow through on all initiatives implemented, and all projects undertaken.
  • Mastery of desktop applications, including MS Office (Word, PowerPoint, Excel, and Access).
  • Expert knowledge of quality systems such as ISO 9001, Toyota Production System, Baldrige. (Preferred)
  • Bachelor’s Degree in related field (e.g., healthcare or business).
  • Three years’ experience in designing, planning and executing audits and effectively communicating results to senior leadership.
  • One year of supervisory/managerial experience
  • Master’s Degree in related field (e.g., healthcare or business) (Preferred)
  • Certified Professional in Healthcare Quality (CPHQ) (Preferred)
  • CPPS (Certified Professional in-Patient Safety) or equivalent (Preferred)



Licensure, Certification, or Registration Required:

  • Active Florida license as one of the following:
  • Registered Nurse
  • Speech Pathologist
  • Physical Therapist
  • Occupational Therapist
  • Respiratory Therapist
  • Doctor of Osteopathy
  • Doctor of Podiatric Medicine
  • Pharmacist
  • ARNP
  • Radiology Tech
  • Physician Assistant
  • Certification from a nationally-recognized body as an ISO 9001 Lead Auditor
  • Certified Professional in Healthcare Quality (CPHQ) (Preferred)
  • CPPS (Certified Professional In-Patient Safety) or equivalent (Preferred)



Job Responsibilities:

Demonstrates through behavior AdventHealth’s Core Values of Keep Me Safe, Love Me, Make it Easy, and Own it as outlined in the organization’s Performance Excellence Program.
  • Implements systematic approach to create and maintain reliable processes and continuous learning for audit and document control.
  • Responsible for the management of the system audit team including clinical and environment of care including budget, hiring and ongoing management
  • Collaborates with Infection Prevention, Risk Management, Safety and Transformational Care to build an audit plan to assess key areas of performance for ACS and IHS
  • Develops and manages the team that has oversight for all Document Control processes for the organization including but not limited to policies & procedures, SOPs, work instructions, educational materials, management system and contracts
  • Responsible for the Quality Assurance/Performance Improvement committee management and execution, ensuring the pace and coverage of all required items from the Centers for Medicare/Medicaid (CMS) conditions of participation, audit reports and high risk, problem prone areas.
  • Responsible for communication and responses to the Quality Improvement Officer (QIO) to interested stakeholders
  • Serves as the organization-wide content expert on regulations/accreditation standards (e.g. DNV, CMS, AHCA, etc.) and imparts relevant details to senior leaders and quality staff. Continually expands/updates this knowledge.
  • Develops and manages the organizational Internal Audit plan in partnership with other audit functions within AdventHealth (e.g., Infection Control, Finance), including topics, frequency, method, responsible audit team(s) and information flow.
  • Ensures the audit of accreditation/regulatory readiness – identifies and escalates risks. Assists in the coordination of organization-wide accreditation/regulatory surveys (DNV, CMS, etc.).
  • Effectively communicates the results of Internal Audits to various levels of leadership and identifies opportunities for corrective action.
  • Works with the senior team to plan, manage and execute on annual accreditation surveys
  • Responsible for the development and execution of the system wide audit plan
  • Develops the annual plan for survey preparation and execution, incorporating new standards and policies from CMS
  • Establishes and cultivates a culture where teamwork thrives based on communication and ‘just culture’ approach to mistakes.
  • Integrates the strategies of reliable processes and continuous learning with structure to make safety the accepted way of doing business.
  • Guides consistent improvement within the organization by reducing errors and enhancing patient safety, measures clear outcomes and associated metrics, visible internally to people doing the work and externally to public.
  • Manages the Clinical and Physical Environment audit teams. Ensures the effective internal audit of regulations, standards, policies and procedures such as Corrective/Preventive Action, Document Control and Control of Non-Conforming Product.
  • Oversees the education and competence of Clinical and Physical Environment auditors on relevant standards/regulations.
If you want to be a part of a team that is dedicated to delivering the highest quality in patient care, we invite you to explore the Audit/Accreditation Manager opportunity with AdventHealth Orlando and apply online today.



Job Keywords:

Audit/Accreditation Manager, Quality/Safety, Orlando



Position Location:  Orlando
Job:  Other Clinical Professional
Organization:  AdventHealth Central Florida
Primary Location:  US-FL-Orlando
Schedule:  Full-time
Shift:  Day
Job Level:  Staff / Associate
Education Level:  Bachelor's Degree
Travel:  No
Job Posting:  Jun 27, 2019, 11:04:31 AM

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