Director Quality Services at AdventHealth

Date Posted: 8/21/2019

Job Snapshot

  • Job Schedule
  • Location:
    Sebring, FL
  • Job Category
  • Date Posted:
  • Job ID:
  • Job Family
    Quality/Clinical Effectiveness
  • Travel
    Yes, 50 % of the Time
  • Shift
    1 - Day
  • Application Zone
    1-Shared Services
  • Organization
    AdventHealth Sebring Wauchula Lake Placid

Job Description


Director Quality Services AdventHealth Sebring

Location Address: 4200 Sun 'n Lake Boulevard Sebring, FL 33872

Top Reasons to Work at AdventHealth Sebring

  •  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

Work Hours/Shift:

Full Time/Days

You Will Be Responsible For:

  • Manages processes related to Inpatient Quality Measures, Outpatient Quality Measures, Premier Quest, Safety Attitudes Questionnaire, Patient Safety, The Joint Commission, and National Healthcare Safety Network.
  • Serves as primary contact for Premier, Centers for Disease Control, The Joint Commission, Pascal Metrics, FMQAI, and other partners in improvement and accreditation activities
  • Identifies and presents cases to the Medical Staff Triage/Quality Committee and Quality Committee of the Board.
  • Acts as internal consultant to the Medical Staff, Administration, all Clinical and Ancillary Departments regarding regulatory compliance issues and quality improvement processes.
  • Analyzes, interprets, trends quality related data and partners with department leaders to develop plans to improve.
  • Coordinates Safety and Emergency Management activities with the Safety Officer and Emergency Management Coordinator, including Hazard Vulnerability Analysis, evaluation of Emergency Drills and annual risk assessments.
  • Coordinates The Joint Commission applications, surveys, preparation, and follow-up activities
  • Performs the 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.
  • Works in collaboration with Risk Management to develop and implement plans that supports patient safety initiatives.
  • Facilitates inter/intradepartmental participation in quality improvement teams.
  • Maintains Performance Improvement, Patient Safety, and Infection Control standards in accordance with Accrediting and Regulatory agencies.
  • Oversees Performance Improvement/Patient Safety, and Infection Control plans, updating and revising as needed.
  • Participates in accomplishing the Clinical Performance Improvement initiatives and Corporate Clinical Accountabilities identified by the organization.
  • Participates in Performance Improvement team formation and facilitation.
  • Performs individual case review and root-cause analysis in conjunction with clinicians as requested.
  • Recognizes potential code 15 and/or Sentinel Event cases and reports them to Risk Management within 48 hours of discovery.
  • 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.
  • Develops and manages the Spiritual Life Plan and Staff Engagement Plan for the department.
  • Manages the Clinical Resources (Quality) department.
  • Communicates information from management meetings to staff.
  • Provides recommendations to modify and/or improve processes/flow of Department.
  • Demonstrates a restlessness to improve organization-wide systems and processes.
  • Pursues educational opportunities for Professional growth.
  • Other duties as assigned.


What You Will Need:

  • Three (3) years in Performance Improvement Management/Leadership Role
  • Computer literate and proficient in – database management
  • Education in Performance Improvement such as Team Leader, Facilitator experience, Malcolm Baldrige and LEAN Six Sigma
  • Excellent Communication/Motivational skills.
  • Experience in Performance Improvement -Statistical Data Analysis


Experience in Human Factor analysis



Bachelor of Science, Nursing


  • Masters of Science, Nursing, Masters in Business Administration or Masters in Health Care related field




State of Florida License in Registered Nurse


  • Certification in Infection Control and Epidemiology
  • Certification in Healthcare Quality (CPHQ)
  • Certification in Healthcare Accreditation

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

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