Director of Quality and Accreditation - Texas Health Mansfield- operated as joint venture between Texas Health Resources and AdventHealth
Location: 2300 Lone Star Road; Mansfield, TX
Top Reasons to Work at Texas Health Mansfield; Mansfield, TX
Â·Join a family of caregivers focused on whole-person health and committed to making communities healthier.
Â·Provide wholistic care for patients that extends to the spiritual level by praying with patients and families.Chaplains are available to meet with patients, families and team members 24 hours a day, 7 days a week to provide spiritual support.
Â·Help develop a brand new $150 million community hospital and medical office building that will provide services such as Medical/Surgical, ICU, Womenâ™s Services, General Surgery, Orthopedics, Interventional Cardiology and Gastroenterology.
Â·Grow in your career with AdventHealth, named in 2018 by Beckerâ™s Hospital Review as one of the âœ150 Top Places to Work in Healthcareâ.AdventHealth has partnered with Texas Health Resources, named in 2019 as one of Fortuneâ™s 100 Best Companies to Work For, to build Texas Health Mansfield, which is creating new opportunities for employment and professional growth.
Â·Thrive in the Mansfield community, ranked by CNN/Money Magazine as #17 for âœBest Places to Liveâ.Mansfield is one of the fastest growing areas of North Texas, projected to reach more than 250,000 residents by 2023.Future job growth over the next ten years is predicted to be 41%, higher than the national average of 33.5%.Mansfield has top-rated schools, over 900 acres of parkland, quality housing, a historic downtown area, recreational opportunities for all ages, and a growing business community.
You Will Be Responsible For:
Â·Responsible for developing and implementing an organization-wide quality assurance / performance improvement program
Â·Coordinates monthly Quality Management Council and ensures timely reporting of key quality metrics
Â·Prepares quarterly board reports and annual summary
Â·Maintains current knowledge of State, CMS, Joint Commission and other regulatory standards and assesses facility compliance
Â·Serves as Joint Commission liaison and ensures timely completion of survey applications
Â·Serves as primary survey coordinator for all accreditation visits
Â·Oversees all post-accreditation activities and any follow up action plans
Â·Perform chart audits for key focus areas
Â·Oversees and works collaboratively with Risk Management to facilitate external peer reviews
Â·Directly supervises Quality/Accreditation/Risk Management/Patient Safety/Infection Prevention departments.Is responsible for the overall direction, coordination and evaluation of the units and employees.
Â·Carries out supervisory responsibilities in accordance with the organizationâ™s policies and applicable laws.In conducting these activities, the Quality / Accreditation Director will exercise independent judgement and discretion in the interest of Texas Health Hospital Mansfield.Responsibilities include:interviewing, hiring and training employees: planning, assigning and directing work; appraising performance; rewarding and disciplining employees; addressing complaints and resolving problems; effectively conducts counselling, disciplinary and termination sessions as needed, utilizing organizational and management skills;analyzes performance and prepares evaluations and effectively conducts annual performance reviews for subordinates in accordance with organizational policy and procedure
What will you need:
Requires critical thinking skills, decisive judgment and the ability to work with minimal supervision
Must be able to work in a stressful environment and take appropriate action
Current unrestricted state of Texas RN license
Bachelorâ™s Degree in Nursing
Three yearsâ™ experience in quality management, quality measures, accreditation, acute care regulation, and patient safety initiatives
Working knowledge in the concepts associated with performance improvement
Previous experience with Medicare and Joint Commission surveys needed
Masterâ™s Degree in Nursing or related healthcare field preferred
Certified Professional Healthcare Quality (CPHQ) highly preferred
Responsible to oversee the development and implementation of an organization-wide Quality Assurance / Performance Improvement Plan which includes outpatient services, along with patient safety and infection control regulations. Work collaboratively with all departments to ensure safe, effective and reliable service.Responsible for all aspect of accreditation including application, survey readiness, survey follow up activities. Oversee hospital performance related to value-based-purchasing and identify opportunities for improvement.Must maintain current knowledge of Medicareâ™s Condition of Participation, The Joint Commission Standards for Hospital Accreditation, and Texas State regulations.
AdventHealth Greater Orlando (formerly Florida Hospital) is one of the largest faith-based health care providers in the United States. For 150 years, we have carried on a tradition of providing whole-person care that not only addresses patients' physical ailments, but also supports their emotional and spiritual well-being. We demonstrate the same level of compassion and care for our employees as well, doing all that we can to help them realize their full potential – both personally and professionally.
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