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Regulatory Consultant
4 months ago
Position Summary What You Will Do: The Regulatory Consultant functions as a consultant to Orlando Health in the area of healthcare accreditation regulations, standards, and clinical performance improvement. Responsibilities Responsibilities: * Coordinates external body regulatory/accreditation surveys for the organization. Communicates directly with The Joint Commission (TJC) account executive or Standards Interpretation Group for clarification of standards or requirements. * Responsible for completion of components of The Joint Commission application for submission of required data and documentation. * Ensures accuracy of all data submitted to regulatory or accreditation organizations. * Performs mock surveys to evaluate compliance with The Joint Commission/CMS standards and requirements. Trains additional identified team members to perform focused mock surveys using specific tracer tools. * Develops tracer tools or other specific focus tools for use in mock survey process or evaluation of compliance with specific regulatory/accreditation/ certification requirements. * Provides oversight for Orlando Health Patient Care Policies and Procedures and compliance with National Patient Safety Goals. * Educates organization leadership and medical staff on changes to accreditation /regulatory requirements. * Provides regulatory guidance and support to medical staff and operations leaders /councils pursuing specific TJC certifications. * Coordinates application submission, site survey and follow up actions. * Actively performs audits to evaluate compliance on regulatory requirements. Directs development and implementation of action plans to address non-compliance. * In conjunction with site leadership, actively facilitates site Regulatory Council to support ongoing TJC readiness and sustainability. * Assists internal customers with performance improvement initiatives which support the Strategic Goals of Orlando Health. * Directs improving compliance with and understanding of all healthcare regulations and standards. * Mentors and provides guidance for the development of educational opportunities for the organization relative to standards and accreditation regulations. * Works with Orlando Health's leaders to communicate mock and actual survey findings and directs the completion of corrective action plans to address deficiencies. * Directs development and maintenance of unit based medical record review data base. Analyzes data, interprets results. Facilitates development of action plans with nursing unit leaders to address areas of non-compliance. * Develops and maintains effective working relationship with the medical and operations staff. * Maintains reasonably regular, punctual attendance consistent with Orlando Health policies, the ADA, FMLA and other federal, state and local standards. * Maintains compliance with all Orlando Health policies and procedures. Other Related Functions * Represents the Regulatory Department and Orlando Health at external meetings and seminars. Adheres to Orlando Health policies and procedures, value statement and PROMISE Standards. * Attends external accreditation/regulatory education sessions/programs to enhance knowledge of regulatory/accreditation requirements. Actively seeks learning experiences and assumes responsibility for own professional growth. * Works closely and in collaboration with all departments of Orlando Health. * Demonstrates excellent verbal, written, and presentation skills in order to communicate cooperatively and constructively with physicians and members of the healthcare team. Qualifications Education/Training * Bachelor's degree in healthcare, nursing, allied health or closely related field. Licensure/Certification * If RN, maintain license with Florida Department of Health - renewed biannually * If Allied Health professional, maintain license with Florida Department of Health as appropriate for profession. Experince * Five (5) years of clinical or related experience, including experience in healthcare quality/performance improvement projects. Education/Training * Bachelor's degree in healthcare, nursing, allied health or closely related field. Licensure/Certification * If RN, maintain license with Florida Department of Health - renewed biannually * If Allied Health professional, maintain license with Florida Department of Health as appropriate for profession. Experince * Five (5) years of clinical or related experience, including experience in healthcare quality/performance improvement projects. Responsibilities: * Coordinates external body regulatory/accreditation surveys for the organization. Communicates directly with The Joint Commission (TJC) account executive or Standards Interpretation Group for clarification of standards or requirements. * Responsible for completion of components of The Joint Commission application for submission of required data and documentation. * Ensures accuracy of all data submitted to regulatory or accreditation organizations. * Performs mock surveys to evaluate compliance with The Joint Commission/CMS standards and requirements. Trains additional identified team members to perform focused mock surveys using specific tracer tools. * Develops tracer tools or other specific focus tools for use in mock survey process or evaluation of compliance with specific regulatory/accreditation/ certification requirements. * Provides oversight for Orlando Health Patient Care Policies and Procedures and compliance with National Patient Safety Goals. * Educates organization leadership and medical staff on changes to accreditation /regulatory requirements. * Provides regulatory guidance and support to medical staff and operations leaders /councils pursuing specific TJC certifications. * Coordinates application submission, site survey and follow up actions. * Actively performs audits to evaluate compliance on regulatory requirements. Directs development and implementation of action plans to address non-compliance. * In conjunction with site leadership, actively facilitates site Regulatory Council to support ongoing TJC readiness and sustainability. * Assists internal customers with performance improvement initiatives which support the Strategic Goals of Orlando Health. * Directs improving compliance with and understanding of all healthcare regulations and standards. * Mentors and provides guidance for the development of educational opportunities for the organization relative to standards and accreditation regulations. * Works with Orlando Health's leaders to communicate mock and actual survey findings and directs the completion of corrective action plans to address deficiencies. * Directs development and maintenance of unit based medical record review data base. Analyzes data, interprets results. Facilitates development of action plans with nursing unit leaders to address areas of non-compliance. * Develops and maintains effective working relationship with the medical and operations staff. * Maintains reasonably regular, punctual attendance consistent with Orlando Health policies, the ADA, FMLA and other federal, state and local standards. * Maintains compliance with all Orlando Health policies and procedures. Other Related Functions * Represents the Regulatory Department and Orlando Health at external meetings and seminars. Adheres to Orlando Health policies and procedures, value statement and PROMISE Standards. * Attends external accreditation/regulatory education sessions/programs to enhance knowledge of regulatory/accreditation requirements. Actively seeks learning experiences and assumes responsibility for own professional growth. * Works closely and in collaboration with all departments of Orlando Health. * Demonstrates excellent verbal, written, and presentation skills in order to communicate cooperatively and constructively with physicians and members of the healthcare team.
