Position Highlights:

The Regulatory & Accreditation Safety Specialist is responsible for monitoring, trending, implementing and improving the enterprise-wide continuous survey and accreditation readiness plan. Working in collaboration with the Director of Quality and Patient Safety and the leadership of the Center, the specialist will assist all areas in improving their state of readiness and sustaining a state of continuous readiness for regulatory and accreditation surveys for all federal, state, local and accrediting bodies, both mandatory and voluntary certifications.

This position will serve as the regulatory and accreditation subject matter expert in all areas of the Center. The specialist, in collaboration with department leadership, formulates a unit-based continuous readiness plan and monitors trends in compliance via tracer data analysis. The position works with areas in need of assistance in meeting guidelines utilizing best practice methodology for performance improvement. The specialist will be included in all regulatory and accreditation visits and be present, when possible, in order to identify issues and work with areas to ensure action plans meet guidelines and timeframes.

This position is responsible for maintaining the regulatory and accreditation data base to track all site visits, mail requests, the issues involved, the responses and action plan compliance. The position will lead or participate in Process Improvement projects as identified and in collaboration with Quality and Patient Safety Manager/Director. Enhancing patient safety and quality of care is integral to this role.

The Ideal Candidate:

• Excellent team building, communication and presentation skills
• Demonstrated Project Management Skills
• Superior Microsoft Office skills
• Strong critical thinking skills
• Strong consulting skills, including team building, identifying opportunities for improvement, collaboratively working with leadership to create realistic and manageable action plans.

Responsibilities:

• Ensure Moffitt Cancer Center is in a state of perpetual readiness for TJC, CMS, FDA and OSHA standards
• Coordinates Standard Specific Tracer Activity
• Coordinates and maintains regulatory documentation
• Supports the coordination of the annual TJC Focused Standards Assessment
• Provides support and acts as a resource in matters regarding patient safety, environment of care, emergency management, performance improvement, medical staff and accreditation
• Lead projects utilizing project management skills

Credentials and Qualifications:

• Bachelor’s Degree – Field of Study in Nursing or other relevant field
• Five (5) years of clinical experience with at least three (3) of the years specializing in medical staff quality, patient safety and healthcare regulations. Must have prior regulatory and tracer experience as well as experience conducting peer reviews and agency surveys.
• Registered Nurse (RN)
• HACP – Healthcare Accredited Certified Professional Required

Preferred:

• Master’s Degree – Nursing or other relevant study
• Project Management Certification
• Certified Professional in Healthcare Quality (CPHQ)
• Lean Six Sigma Certification