BAPTIST HEALTH BROOKWOOD HOSPITAL
Serving the Homewood community, Baptist Health Brookwood Hospital is a 595-bed acute-care hospital located in Birmingham, Alabama. The facility offers a full complement of services, including emergency care, cardiovascular care, bariatrics, orthopedics and rehabilitation, and surgical services. It also is one of the largest providers of psychiatric care in the state. The hospital has earned Primary Stroke Center certification from The Joint Commission, and its bariatric program has been accredited as a Comprehensive Center by the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP). The Women’s Medical Center provides comprehensive women’s services through all stages of life, including gynecologic surgery, maternity care, and labor and delivery services. Additionally, the Level III Neonatal Intensive Care Unit (NICU) holds Advanced Certification in Perinatal Carefrom The Joint Commission.

Baptist Health Brookwood is part of the Orlando Health system of care, which includes award-winning hospitals and ERs, specialty institutes, urgent care centers, primary care practices and outpatient facilities that span Florida’s east to west coasts, Central Alabama and Puerto Rico. Collectively, our team members honor our over 100-year legacy by providing professional and compassionate care to the patients, families and communities we serve. Orlando Health is committed to providing you with benefits that go beyond the expected, with 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

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

Location: 

Position will be seated at Baptist Health Brookwood Hopsital 

Homewood, AL 

Shift: M-F

Baptist Health Citizens Hospital Offers Great NEW Competitive Pay and Great Benefits Package that Includes:

Medical, Dental, Vision

403(b) Retirement Savings Plan

Health Savings Account (HSA)

Flexible Spending Account (FSA)

Paid Time Off (up to 5 weeks to start)

Life Insurance

Extended Leave Plan (ELP)

Family Care (childcare, elder care, pet care)

Paid Parental Leave

Pet Insurance

Car Insurance

Educational Benefits including tuition reimbursement & monthly payments to help pay down any graduated school debt

ALL Benefits Start Day One

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.

Education/Training
Bachelor’s degree in healthcare, nursing, allied health or closely related field

Licensure/Certification
If RN, maintain license with Alabama Department of Health – renewed biannually; or
If Allied Health professional, maintain license with Alabama Department of Health as appropriate for profession.
Experience
Five (5) years of clinical or related experience, including experience in healthcare quality/performance improvement projects.