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Regulatory Consultant - Dr Phillips Hospital

Company

Orlando Health
Address , Orlando, 32806, Fl
Employment type FULL_TIME
Salary
Expires 2023-06-17
Posted at 1 year ago
Job Description
Position Summary:
The Regulatory Consultant will be integral to the healthcare accreditation process at Dr. Phillips Hospital. They will focus primarily on healthcare regulations, standards, and clinical performance improvements.

The Consultant will assesses Hospital readiness for Joint Commission compliance, work with operational and physician leadership to provide education and guidance in compliance, and perform routine tracers in clinical and nonclinical departments to educate and prepare team members for accreditation and certification surveys.

In addition, they will leads the Dr. Phillips Hospital Regulatory Council for monthly data and information exchange and routinely perform chart audits for documentation compliance.

About Dr Phillips Hospital:

Dr. Phillips Hospital is a comprehensive medical and surgical acute care facility serving the residents of southwest Orange County for more than 35 years. Conveniently located in the Dr. Phillips community, the 285-bed hospital’s dedicated team of physicians, nurses, clinicians and medical professionals are committed to delivering quality and compassionate care.
Responsibilities:
  • Responsible for completion of components of The Joint Commission application for submission of required data and documentation.
  • In conjunction with site leadership, actively facilitates site Regulatory Council to support ongoing TJC readiness and sustainability.
  • Works with Orlando Health’s leaders to communicate mock and actual survey findings and directs the completion of corrective action plans to address deficiencies.
  • Maintains compliance with all Orlando Health policies and procedures.
  • Actively performs audits to evaluate compliance on regulatory requirements. Directs development and implementation of action plans to address non-compliance.
  • 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 tracer tools or other specific focus tools for use in mock survey process or evaluation of compliance with specific regulatory/accreditation/ certification requirements.
  • Maintains reasonably regular, punctual attendance consistent with Orlando Health policies, the ADA, FMLA and other federal, state and local standards.
  • Develops and maintains effective working relationship with the medical and operations staff.
  • Provides regulatory guidance and support to medical staff and operations leaders /councils pursuing specific TJC certifications.
  • 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.
  • Educates organization leadership and medical staff on changes to accreditation /regulatory requirements.
  • 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.
  • Provides oversight for Orlando Health Patient Care Policies and Procedures and compliance with National Patient Safety Goals.
  • 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.
  • Ensures accuracy of all data submitted to regulatory or accreditation organizations.
  • Assists internal customers with performance improvement initiatives which support the Strategic Goals of Orlando Health.
  • Coordinates application submission, site survey and follow up actions.
Qualifications:
Education/Training
  • Bachelor’s degree in healthcare, nursing, allied health or closely related field.

Licensure/Certification
  • If Allied Health professional, maintain license with Florida Department of Health as appropriate for profession.
  • If RN, maintain license with Florida Department of Health – renewed biannually; or

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