Regulatory Consultant - Doctor Phillips Hospital - Orlando Health

Functions as a consultant to all Orlando Health in the area of healthcare accreditation regulations, standards, and clinical performance improvement.

Essential Functions
 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.

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.

Experience
Five (5) years of clinical or related experience, including experience in healthcare quality/performance improvement projects.