Position Summary 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 27000 team members serve communities that span Floridas 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 its our promise to you. Position Summary Functions as a consultant to all Orlando Health in the area of healthcare accreditation regulations standards and clinical performance improvement. This is supporting Wiregrass Hospital - In Wesley Chapel FL Responsibilities Essential Functions Coordinates external body regulatoryaccreditation 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 CommissionCMS 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 regulatoryaccreditation 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 Healths 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 accreditationregulatory education sessionsprograms to enhance knowledge of regulatoryaccreditation 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 EducationTraining Bachelors degree in healthcare nursing allied health or closely related field. LicensureCertification 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 qualityperformance improvement projects.EducationTraining Bachelors degree in healthcare nursing allied health or closely related field. LicensureCertification 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 qualityperformance improvement projects.Essential Functions Coordinates external body regulatoryaccreditation 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 CommissionCMS 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 regulatoryaccreditation 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 Healths 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 accreditationregulatory education sessionsprograms to enhance knowledge of regulatoryaccreditation 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.