Regulatory Quality Consultant -Strategic Quality Performance

Lakeland Regional Health is a leading medical center located in Central Florida. With a legacy spanning over a century, we have been dedicated to serving our community with excellence in healthcare. As the only Level 2 Trauma center for Polk, Highlands, and Hardee counties, and the second busiest Emergency Department in the US, we are committed to providing high-quality care to our diverse patient population. Our facility is licensed for 910 beds and handles over 200,000 emergency room visits annually, along with 49,000 inpatient admissions, 21,000 surgical cases, 4,000 births, and 101,000 outpatient visits.

Lakeland Regional Health is currently seeking motivated individuals to join our team in various entry-level positions. Whether you're starting your career in healthcare or seeking new opportunities to make a difference, we have roles available across our primary and specialty clinics, urgent care centers, and upcoming standalone Emergency Department. With over 7,000 employees, Lakeland Regional Health offers a supportive work environment where you can thrive and grow professionally.

Active - Benefit Eligible and Accrues Time Off

The Regulatory Quality Consultant (RQS) serves as a subject matter expert for accreditation and regulatory compliance across the health system. This role supports LRHMC and hospital-based sites in maintaining Continuous Readiness with Joint Commission, CMS, and other regulatory requirements. The RQS team member will collaborate with leaders and direct care team members to assess compliance, conduct tracer activities, analyze findings, and guide actions to improve safety, quality, and survey preparedness and share best practices. The RQS provides education, interprets new and evolving regulations, and partners with leadership to strengthen a culture or accountability and performance excellence throughout the organization.

People At The Heart Of All We Do

• Fosters an inclusive and engaged environment through teamwork and collaboration.
• Ensures patients and families have the best possible experiences across the continuum of care.
• Communicates appropriately with patients, families, team members, and our community in a manner that treasures all people as uniquely created.

• Behaves in a mindful manner focused on self, patient, visitor, and team safety.
• Demonstrates accountability and commitment to quality work.
• Participates actively in process improvement and adoption of standard work.

• Demonstrates responsible use of LRH's resources including people, finances, equipment and facilities.
• Knows and adheres to organizational and department policies and procedures.

• Provides guidance and oversight to ensure continuous compliance with federal, state, and other accrediting bodies as identified throughout the health system.
• Required to maintain knowledge of new and existing regulatory developments and concepts, along with an understanding of hospital-based ambulatory regulatory requirements
• Proactively develops and enhances interdisciplinary partnerships. Collaborates with clinical and operational leaders to interpret regulatory requirements, assess compliance risks, and support survey/continued readiness
• Applies clinical expertise and regulatory knowledge to promote safety, quality outcomes, and operational excellence
• Conducts proactive tracers and risk assessments to identify compliance gaps
• Provides consultation to nursing and interprofessional teams on regulatory requirements, patient safety, and best practices
• Supports continuous readiness activities, tracers, mock surveys, and corrective action planning
• Collaborates with Learning and Organizational Development (LOD) and Nursing Professional Practice and Development (NPPD) to deliver regulatory education and training to frontline team members.
• Tracks and analyzes compliance trends for sharing of opportunities and departmental best practices
• Partners with Clinical Quality, Infection Prevention, Resolution Services, NPPD, Support Services, Med Staff, and Nursing Leadership to ensure an integrated approach to compliance
• Advocates for zero preventable harm by demonstrating keen attention to safety and quality practices by recommending and facilitating process and system changes to reduce the likelihood of errors and adverse events. (Clinical Quality Consultant RN Position Description)
• Remains astute of the data metrics that are publicly reported with a focus on improving unit and system-level outcomes. (Clinical Quality Consultant RN Position Description)
• Guides system changes with optimization for sustainment of quality and patient safety initiatives, monitoring compliance of standard work. (Clinical Quality Consultant RN Position Description)
• Champion for evidence-based practice, clinical inquiry and nursing research. Fostering development of clinical judgement of health team members through role modeling, teaching, coaching, evidence-based practice, quality improvement projects and/or mentoring. Assists with educational initiatives as related to improvement in outcomes and quality of care. (Clinical Quality Consultant RN Position Description)
Reviews and updates policies and procedures as necessary. Is responsible for bringing awareness of all noted performance improvement opportunities, identified trends, and prioritizes needs with communication to unit and Strategic Performance & Quality Improvement Leadership for any gaps in compliance. (Clinical Quality Consultant RN Position Description)

Essential:

• Displays strong planning and organization, critical thinking and decision-making skills. High degree of confidentiality, maturity, tactfulness and business ethics. High degree of self-motivation, commitment and integrity. Communicates proactively to prevent problems.
• Demonstrates sophisticated judgment in balancing competing demands
• Shows ability to work independently and to organize multiple, complex projects and see them through to timely completion. Works as an empowered member of a self-directed work team committed to a common purpose and goals and holds self mutually accountable for system outcomes
• Possesses exceptional interpersonal skills and emotional intelligence. High level of written and verbal communication skills to relay performance improvement issues and concerns with tact and diplomacy Strong coaching, mentoring, negotiation, and conflict resolution skills are needed to deal effectively with team members and the community when representing the health system
• Exhibits competency in using Word, Excel, PowerPoint, and databases. Evaluates research found in sources on the basis of accuracy, validity, appropriateness for needs, importance, and social and cultural context. Has knowledge of research and capacity to interpret findings. Is accountable for self-engagement in educational activities related to specialty and professional practice

• Previous performance and quality monitoring experience
Ability to transform data into information easily understood by others

Nonessential:

Other information:

Experience Essential:

- Minimum of five years in professional healthcare role

Experience Preferred:

-

Certifications Essential:

Basic Cardiac Life Support

Expectation for certification in accreditation within 2 years of hire

Certification Preferred:

Certification in Specialty of Nursing and/or Advanced Practice

Certification in current role preferred with expectation for future certification