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A** **ll the benefits and perks you need for you and your family:

+ Benefits and Paid Days Off from Day One

+ Paid Parental Leave

Our promise to you:

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.

**Schedule** : Full-time

**Shift:** Exempt Salaried Position

The role you’ll contribute:

The Executive Director, Clinical Excellence serves as the executive leader responsible for developing, managing, and continuously enhancing a comprehensive quality program that drives clinical excellence and high-value care delivery across the 8 hospitals in AdventHealth's Central Florida Division, South Region (CFD-South). This individual will provide broad oversight and strategic direction for all core aspects of quality, clinical outcomes, regulatory compliance, and public reporting of clinical performance. The Executive Director will collaborate closely with physician leaders, hospital executives, and nursing leaders to ensure alignment on quality priorities and develop strategies to optimize safe, high-quality, patient-centered care. This role will provide oversight and management of key quality metrics including but not limited to Leapfrog Hospital Safety Grade and Survey, CMS Star Ratings, mortality, reductions in healthcare associated infections, and readmissions. They will liaise with medical staff, Institute and AHMG physician leaders to build relationships that drive physician engagement on evidence-based care, national best practices, and ensure that clinical performance is reflected in the highest ratings for AH CFD-South public reporting.

The value you’ll bring to the team:

Leads the development and execution of comprehensive annual quality and clinical performance improvement plans that align with corporate clinical strategic initiatives and vision.

• Collaborates extensively with the Regional Chief Clinical Officer, Regional Chief Nursing Officer, Hospital Chief Medical Officers, Chief Nursing Officers, ancillary leaders, and physician leaders to drive engagement and performance on quality priorities and evidence-based care.

• Serves as matrix leader for outcomes and quality leaders at each campus. Provides strategic direction on clinical excellence priorities for the region and leads the development of quality initiatives to improve clinical performance.

• Provides oversight and management of Leapfrog Hospital Safety Grade and Survey, targeting top decile national performance. Leads strategies to achieve and maintain CMS 5-star rating.

• Responsible for collaborating with clinical program leaders across the care continuum of CFD-South to achieve clinical excellence accountability measures and improve quality measures. This includes but not limited to home health, hospice, skilled nursing facilities, rehab, etc.

• Responsible for ensuring AH CFD-South compliance and accuracy of all required quality reporting for AHCA and CMS. This includes overseeing all quality measures and attestations for the CFD-South region campuses.

• Monitors performance in corporate accountabilities, including but not limited to mortality rates, healthcare associated infections, readmissions, and AHRQ patient safety indicators, and other clinical performance indicators. Establishes goals and initiatives to drive improvements.

• Prepares for the regional Board Quality and Safety Committee meetings. Develops executive summary slides, compiles data reports, and builds corrective action plans as part of comprehensive performance updates.

• Leads development of quality action plans for corporate accountability initiatives such as AH Clinical Excellence Review and AH Corporate Performance Review. Presents quality plans in executive forums as assigned.

• Serves as subject matter expert on all areas of quality and clinical excellence performance including measure specifications. Responsible for forecasting changes to quality measures based on national landscape, regulatory, or payor requirements and developing strategic plans to meet clinical quality performance goals.

• Ensures regulatory compliance with all applicable quality standards and regulations such as Det Norske Veritas, AHCA, and CMS requirements.

• Provides complete operational and strategic management for quality budget across 8 hospitals, including staffing, contracts, and resources.

• Recruits, hires, develops and retains high-performing quality management team for region with more than 2,900 acute care beds.

Qualifications

What You Will Need:

Expert understanding of clinical quality, performance improvement, and regulatory compliance principles.

• Excellent data analysis and problem-solving skills. Able to derive insights from complex data.

• Knowledge of accreditation standards such as CMS, DNV, and state regulations.

• Knowledge of change management and project management methodologies.

• Proficient in Microsoft PowerPoint, Word, and Excel. Ability to develop visually compelling presentations.

• Ability to collaborate and build relationships with physicians, executives, and stakeholders.

• Capacity to handle high stress, shifting priorities, and handle multiple complex projects simultaneously.

• Exceptional written and verbal communication skills including the ability to influence in a collaborative manner, persuade teams, up to and including the executive level, to build consensus within and across stakeholder groups (high-level negotiation skills)

• Mastery of performance improvement methodology and tools

• Analytical and managerial ability; motivational and team-building skills

• Excellent facilitation skills in various PI methodologies (Six Sigma, Lean, PDSA, etc.)

• Advanced ability to oversee multiple and varied projects with enthusiasm and prioritize workload with attention to detail

• Ability to mentor, enhance and engage organizational talent

• Business, financial management and budgeting expertise

EDUCATION AND EXPERIENCE REQUIRED:

• Graduate of an accredited School of Nursing

• Bachelor’s degree in nursing or healthcare related field with 5 years of experience

• Minimum five years’ progressive healthcare management experience

• Quality program development, process improvement and project management

• Development and implementation of large-scale clinical initiatives

• Experience with administrative quality databases (Vizient, Premier, Quantros, etc)

• Experience with national quality programs (Leapfrog, CMS 5-Star, U.S. News, etc.)

EDUCATION AND EXPERIENCE PREFERRED:

• Master’s degree in Nursing or other healthcare-related field

LICENSURE, CERTIFICATION OR REGISTRATION REQUIRED:

• Current valid State of Florida or multi state license as a Registered Nurse

LICENSURE, CERTIFICATION OR REGISTRATION PREFERRED:

• Certified Professional in Healthcare Quality (CPHQ)

Lean Six Sigma Performance Improvement Certification

This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances. The salary range reflects the anticipated base pay range for this position. Individual compensation is determined based on skills, experience and other relevant factors within this pay range. The minimums and maximums for each position may vary based on geographical location.

**Category:** Nursing

**Organization:** AdventHealth Orlando

**Schedule:** Full-time

**Shift:** 1 - Day

**Req ID:** 25022059

We are an equal opportunity employer and do not tolerate discrimination based on race, color, creed, religion, national origin, sex, marital status, age or disability/handicap with respect to recruitment, selection, placement, promotion, wages, benefits and other terms and conditions of employment.