Performance Improvement Regulatory Coordinator Full Time Day in DeLand, FL at Adventist Health System

Date Posted: 11/11/2018

Job Snapshot

  • Job Schedule
  • Location:
    DeLand, FL
  • Job Category
  • Date Posted:
  • Job ID:
  • Job Function
    Risk Management
  • Travel
  • Shift
    1 - Day
  • AHS Zone
    1-Shared Services
  • Organization
    Florida Hospital DeLand

Job Description


Work Hours/Shifts

Full Time, Days

Florida Hospital DeLand

For over 50 years, Florida Hospital DeLand, a full-service, 156-bed acute care hospital located in DeLand, FL, has served the West Volusia area and surrounding communities. Florida Hospital DeLand has grown to include Florida Hospital DeLand Victoria Medical Park, Florida Hospital Digestive Health Center and the Florida Hospital DeLand Cancer Institute. We are fully accredited by the Joint Commission on Accreditation of Health Care Organizations; which includes being awarded their Gold Seal of Approval. Our efforts to strive for excellence has led to being voted “Best Hospital and Best Rehab” by Best of the West — Daytona News Journal and a Top 100 Company for Working Families in Central Florida.

At Florida Hospital DeLand, we believe that better quality of care leads to better quality of life, so we’re committed to providing each of our patients the absolute best medical care in the most cutting-edge facilities possible, all in a caring, compassionate, neighborly environment. Our mission is to offer hope and healing to all of our patients in conjunction with our mission to extend the healing ministry of Christ within our community.

  • Serves as a hospital content expert on performance improvement projects, quality measure consoles and documentation, accreditation and safety. Provides leadership and support regarding questions from staff, leaders and physicians on performance improvement, quality measures, regulatory and accreditation. Utilizes outside resources for complex questions to ensure correct communication and interpretation (i.e. TJC intranet, ECRI, QualityNet websites).
  • Participates in collaboration with or as the designee for the Quality Director, on AHS quality initiatives and/or collaboratives. This may include but is not limited to: Glycemic management, Partnership for Patients/HIIN, AHRQ safety indicators as assigned. Assists with data management, performance improvement, medical record review and meeting organization to help ensure initiative success and goals are met. Utilizes appropriate PowerInsight (PI) reports to coordinate performance improvement and safety projects.
  • Liaison for the medical staff physician Medical Review and OPPE/FPPE process. This position represents the Office of Clinical Effectiveness at medical staff committees, performance review councils, and hospital leadership meetings by providing regulatory, quality and safety updates as assigned.  Responsible for ensuring all cases referred to Medical Review are dealt with according to hospital Medical Review policy and medical staff bylaws. This may include screening, reviewing with appropriate department chairman, preparing cases to be brought to committee, completing agenda/minutes for committee meeting, communicating committee decisions to involved medical staff providers and providing updates to Medical Executive Committee and hospital Executive Council. Maintains familiarity with medical staff bylaws as an internal content expert.
  • Responsible for maintaining daily screening process for all inpatient admission throughout hospital. Utilizes appropriate PI reports as verification tool to ensure all patients with coded diagnosis for core measures after discharge have all measures addressed. Responsible for reviewing patient medical records to determine key core measure diagnosis, initiates quality consoles and reviews adherence of documentation to quality measures. When discrepancy or variance is noted, responsible for notifying front line nurse, physician and/or  leadership to ensure correction is made prior to discharge or chart completion deadline. Responsible for completing monthly core measure abstraction by abstracting date elements into corporate approved vendor software. Responsible for utilizing CMS data specification manual and maintaining knowledge on measure definitions to ensure accurate and complete data abstraction. Responsible for performing error checking and validation procedures in conjunction with Premier liaison prior to monthly submission. Responsible for completing all abstraction by AHS monthly and CMS quarterly deadlines.
  • Plans, implements & monitors interventions to ensure evidence-based practices are implemented and participates in and/or leads performance improvement committees and teams. Leads special projects for the Chief Medical Officer, Quality Director and Quality Manager while using judgment for the level of discretion and confidentiality needed.
  • Prepares reports and statistical analysis for medical staff and hospital leadership meetings.  Routinely utilizes sensitivity and diplomacy in daily interactions with others as many deal with sensitive, confidential or controversial information. 
  • Patient safety and/or risk management designee when quality director and risk manager are out of the hospital or need additional support. Complete and analyze quality event timelines, root cause analysis timelines, review core measure cases, review risk events, notify regulatory bodies of any Code 15 or other reportable events, and identify care variation in case reviews. 
  • Assures facilitation of the patient grievance process as required by state and federal statutes. Assures that grievances are investigated and directs inquiries and complaints to appropriate directors and managers for follow up. Participates in grievance mediations when necessary. Active member of the board delegated grievance committee. Completes investigations of complaints about medical care which involve a member of the medical staff and communicates need for referral to the Performance Improvement Committee, medical director, Patient Safety Committee, Medical Review Committee and/or Citizenship Committee to the Risk Manager. Maintains data collection and grievance tracking and trending to include unsolicited complaints as well as solicited comments (Gallup surveys, comment boxes, etc.). Independently manages patient relations hotline for grievance/complaint calls and directs information to the appropriate member of the leadership team as appropriate.  Responsible for all incoming and outgoing correspondence, ensuring appropriate follow-up, including drafting of response correspondence.  Immediately advises Director and/or Managers of mail requiring a response and/or important or urgent mail. Writes correspondence on behalf of Director and/or Managers as necessary.
  • Responsible for all incoming and outgoing correspondence, ensuring appropriate follow-up, including drafting of response correspondence.  Immediately advises Director and/or Managers of mail requiring a response and/or important or urgent mail. Writes correspondence on behalf of Director and/or Managers as necessary.
  • Oversees compliance with the Ethics, Rights, and Responsibilities standards for The Joint Commission. Ensures leadership and employee education on patient rights and responsibilities. Assist with New Hire Orientation and Nursing Orientation to provide education on performance improvement, quality measures, accreditation and safety. Provides quarterly staff education and coordinates quality measure and patient safety/regulatory activities for skills fair. May be asked by Quality Director and/or Quality Manager to be responsible for developing weekly performance improvement, quality measures, safety and accreditation tips education flyer and for completing rounds in clinical and non-clinical areas routinely to serve as a resource to staff.
  • Provides analysis of Physician Focus and Quality Advisor reports from the Premier database and produces recommendations for performance improvement projects to hospital leadership. Responsible for evaluation and completion of Premier Error Workbooks by the monthly deadline to ensure availability of evidence-based data analysis.
  • Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all. Provides concurrent case reviews and recommendations to ensure that evidence based best practices are implemented timely.  Responsible for independent coordination of program submissions in compliance with federal guidelines.
  • Responsible for reviewing patient medical records to determine adherence to key quality and safety initiatives in addition to quality measures. When discrepancy or variance is noted, responsible for notifying front line nurse, physician and/or leadership to ensure correction is made prior to discharge or chart completion deadline. Provides leadership for providers, managers and team members on accreditation awareness, safety initiatives, quality measures, and performance improvement projects. Leads and participates in performance improvement initiatives to improve processes, value-based purchasing scores and to ensure patients receive evidence-based care according to the CMS and The Joint Commission standards.
  • Manages multiple calendars to coordinate meetings and events for internal and external stakeholders. Plans for and ensures the orderly occurrence of special events as scheduled. Prepares detailed itineraries when applicable to include events such as dinner meetings, physician meetings and presentations, direct reports’ retreats and special parties/receptions. Coordinates the attendees, materials and resources to ensure streamlined, meaningful performance improvement and risk management meetings/committees/ events. Completes minutes within forty-eight (48) hours or two (2) business days for review. Ensures follow up and includes action items in future agendas.
  • Administers and facilitates debriefing for the annual Safety Culture Survey, Joint Commission survey preparedness rounding, and completion and submission of the Leapfrog Survey.
  • Coordinates annual TJC standards review with executive team and directors and acts as Joint Commission Survey Liaison
  • Assists Quality Director and/or Quality Manager, as assigned, to help with quality and safety initiatives throughout the year. Performs other duties as assigned. This includes, but is not limited to, maintaining department employee files in compliance with regulatory guidelines and maintain intranet for accreditation, patient safety, and performance improvement.
  • Strong computer skills in Microsoft Office Suite (i.e., Word, Excel, Access, PowerPoint, Outlook)
  • Excellent communication skills- written, oral and presentation, to build relationships with all departments, physicians and executive team
  • Must possess presentation skills, as well as negotiation and advocacy skills when interacting with fellow members of the healthcare team as well as outside accrediting agencies, legal bodies, and other healthcare institutions. Internal and external contacts are often problem-driven
  • Analytical ability to interpret data trends
  • Acts independently and demonstrates organizational and problem solving skills
  • Facilitation of various PI methodologies (Six Sigma, Lean, PDSA, etc) preferred.
  • Bachelor’s degree
  • Minimum of 3 years healthcare experience
  • Previous experience in preparing and presenting professional presentations to executive leadership teams
  • Accreditation activities and survey preparation
  • Provider performance improvement activities


  • Bachelor’s degree in a healthcare related field
  • Experience with regulatory, patient safety, Peer Review or OPPE process
  • Healthcare related performance improvement or project management experience
  • Proven ability in areas of leadership/ supervision, knowledge of regulatory aspects of healthcare, QA/QI principles, education and outcomes


  • Certified Professional in Healthcare Quality (CPHQ)
  • Six Sigma Performance Improvement Certification
  • Lean Performance Improvement Certification
  • Certified Professional in Healthcare Risk Management (CPHRM)

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

Location | Organization | Category | Job Function