About the role
Licensure/Certification: • If RN, maintain license with Florida Department of Health – renewed biannually; or • If Allied Health professional, maintain license with Florida Department of Health as appropriate for profession.
About Orlando Health: At Orlando Health, we are ordinary people with extraordinary individuality, working together to bring help, healing and hope to those we serve. By daily embodying our over 100-year legacy, we reinforce our reputation as a trusted and respected healthcare organization that delivers professional and compassionate care to our patients, families and communities. Through our award-winning hospitals and ERs, specialty institutes, urgent care centers, primary care practices and outpatient facilities, our 27,000+ team members serve communities that span Florida’s east to west coasts and beyond.
Orlando Health is committed to providing you with benefits that go beyond the expected, with career-growing FREE education programs and well-being services to support you and your family through every stage of life. We begin your benefits on day one and offer flexibility wherever possible so that you can be present for your passions. “Orlando Health Is Your Best Place to Work” is not just something we say, it’s our promise to you.
- Functions as a consultant to all Orlando Health in the area of healthcare accreditation regulations, standards, and clinical performance improvement 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; or
- If Allied Health professional, maintain license with Florida Department of Health as appropriate for profession.
• Five (5) years of clinical or related experience, including experience in healthcare quality/performance improvement projects Candidates with a perioperative (OR/Surgical Services) background are strongly preferred. 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.