Surveys international health care organizations as assigned. Applies systems analysis skills and inductive reasoning skills to determine a health care organizations' degree of compliance with applicable standards and functionality of care delivery systems. Engages health care organization staff in interactive dialogues on standards based issues in health care in order to assess compliance and to identify opportunities for improving compliance; Prepares exit reports that clearly link individual measurable deficiencies with potential systems vulnerabilities and related organization risk points. Effectively communicates this information to health care organization leadership in a constructive and collegial style. Participates in other Joint Commission International activities as assigned.
Principal Duties and Responsibilities:
Conducts a thorough evaluation of international programs that meet accreditation/ certification eligibility criteria. Reviews and evaluates pre-survey information and conducts all pre-survey activities. Using organization-specific information, selects patient records based upon an evaluation of the client application. Using patient experiences as guides and discussion tools:
In response to patient-centered evaluation activities, analyzes documents, such as policies, procedures, meeting minutes, clinical standards, protocols, patient records, employee records, committee reports, etc. to assess the level of compliance with Joint Commission International standards, implementation of policies, evidence of performance improvement, and quality and safety of care. Using established survey process:
- Conducts analysis of care delivery systems.
- Evaluates patient care environments to assess health care organizations' operations and standards compliance.
- Interviews staff and patients to determine health care organizations' level of compliance with standards.
- Participates in and/or conducts all required on-site activities.
- Documents all observations in a complete and accurate manner utilizing survey technology.
- Participates in on-site/off-site findings integration discussions.
- Provides adequate documentation to guide health care organization improvement activities.
Interprets and explains the intent of standards to the organization's personnel in a constructive, sensitive, and professional manner. Seeks assistance from Central Office when appropriate. Through interactive evaluation sessions consults with organization leaders on high profile issues in health care. Offers relevant consultation where improvement is needed. Communicates organization-specific information to the central office as needed. Maintains current knowledge of Joint Commission International standards, policies and procedures. Maintains current knowledge in professional field of expertise. Demonstrates increasing knowledge of local and regional laws, cultural beliefs and practices pertinent to the survey. Complies with requirements for utilization of all JCIA applications for documenting findings, submitting availability, and competing expense reports, team evaluation tool etc. Participates in evaluating survey team after each survey by completing the Team Evaluation Tool, includes preceptees in training, as requested.Follows clients' safety policies when on site, including following requested safety measures (e.g., wearing appropriate protective clothing or equipment) provided that such policies are not in conflict with Joint Commission International Accreditation policies.Participates in staff development activities. May perform other duties as assigned, including, but not limited to:
- Provides comprehensive rationale for each documented finding.
- Links each observation to potential system-level vulnerabilities found in the measurable elements and opportunities for organizational improvements in patient care and safety.
- Reports survey findings in a complete, accurate, and timely manner.
- Follows JCI Scoring Guidelines to determine a measurable element's score based on evaluation of the evidence.
- Participate in special projects.
- Assist in developing, writing and testing standards, scoring guidelines and the survey process, and provide recommendations for improvement.
- Assists the Central Office in responding to standards interpretation questions from the field.
- Assists the Central Office in analysis of organization intra-cycle monitoring reports, evidence of standards compliance reports and; complaints.
- Serves on JCI Accreditation committees, such as the Surveyor Liaison Group (SLG) Committee.
- Serves as team leader when assigned to a team.
- Serves as faculty for surveyor education and/or field education programs.
- Receives training and conduct surveys across programs and settings.
- Serves as preceptor for surveyors in training.
Education: Masters degree preferred.
Certification/Licensure (at time of hire and throughout employment): Designation of FACHE (Fellow, American College of Healthcare Executives) are preferred.
General Knowledge and Experience: Five years of recent experience and 2 years of senior management experience. Recent experience as a consultant to health care organizations may be considered. Contemporary knowledge of and experience in health care operations, clinical practice, use of performance improvement methods to assess organizational performance, and current research and trends relative to health care practices. Knowledge of Joint Commission International standards and direct involvement with a minimum of two Joint Commission domestic or international surveys. Experience in an international health care setting or preferred.
Specialized Knowledge and Experience: Hospital Accreditation surveyors must have knowledge or experience in various components of a hospital and health care system (i.e., medical staff, quality improvement, medical records, infection control, etc.). Additional experience in other health care settings is preferred.
Critical Thinking Skills:Ability to research, collect, organize, interpret and communicate a large volume of information from multiple sources (i.e., documentation, observation, interviews) to assess the degree of compliance with Joint Commission International standards. Ability to differentiate and assess the adequacy of alternative/innovative approaches to standards compliance, consistent with survey policy and protocols. Ability to analyze and synthesize observations to identify survey findings and educational opportunities. Ability to connect observations and interviews into a comprehensive analysis of the organization's care delivery systems.
Interpersonal Skills: Multi-cultural awareness and sensitivity Respectful of all internal and external customers. Open to inquiry and exchange. Responsive to verbal and nonverbal communication cues.
Problem Solving Skills: Independent decision-making skills to direct and effectively manage the survey process. Ability to objectively assess organization performance. Ability to openly discuss and resolve conflicts/controversy. Ability to seek assistance when appropriate to make decisions, resolve conflicts and/or achieve consensus.
Interviewing Skills: Ability to elicit information through sensitive, appropriate use of open-ended questions and active listening. Ability to further explore observations and received information through effective use of follow-up questioning.
Teamwork Skills: Behavior consistent with Joint Commission International values (i.e., Quality, Respect, Integrity, Courtesy, Teamwork, Recognition, Improvement, Empowerment and Responsiveness). Dependability, including delivering on commitments, assuming appropriate share of all work, being prepared, and adhering to schedules. Candor, including sharing one's own views, encouraging others to share their views, and being willing to offer and receive constructive feedback. Professionalism, including appearance and demeanor.
Organizational Skills: Independently organize work into a smooth flow and to be flexible as necessitated by unique circumstances. Demonstrate effective time management skills.Coordinate activities involving other people.
Written and Verbal Communication Skills: Ability to make presentations and produce written materials which are accurate, clear, concise, complete, well organized, understandable by others, and can be accurately translated into the client's native language if needed. Ability to use a computer or similar technology. Fluent in speaking and writing in English is required, fluent in another language is preferred
Physical Abilities: Must be able to lift 25 pounds. Must be able to climb stairs and ladders.Must be able to work in settings in which dust, allergens and infectious diseases are present. Must be able to observe, in real time and without slowing or otherwise interrupting the progress of, all applicable types of ongoing health care treatment (e.g., including emergency treatment, treatment during weather and other extreme situations, etc.).Standing for long periods of time, walking lengthy distances, lifting, climbing, stooping, pulling, and pushing in order to adequately inspect and observe all medical facilities, equipment and procedures, such as emergency exit procedures, remote storage facilities, any areas where cleanliness may affect the possibility of infection, medical equipment, etc., including the following activities: walking up and down stairways (e.g., to test escape routes, assess safety of emergency exits, regulatory compliance, etc.);removing obstructed covers or impediments to equipment or other mechanical areas;examining small and often dirty printed labels and print on equipment;Must be physically capable of extensive travel 100% of work time including, flying for extended periods of time (at a minimum 10 hours of continuous flight), flying on small airplanes and into small airports, traveling in all types of weather conditions, etc.
Availability: Must be able to travel to all countries where JCI accredits in concordance with the JCI Travel Utilization Policy. Participation in up to one week of corporate orientation and education upon hire. Completion of up to three surveys with a preceptor in order to facilitate understanding of the Joint Commission International standards and their interpretation, survey process, survey technology, presentation techniques, general policies and procedures, and organization structure. Ongoing participation in continuing education activities, including those sponsored by Joint Commission International, (i.e., Invitational Training Conference, regional meetings, other face-to-face meetings, teleconferences, self-directed learning activities, distance learning programs, and special conferences). Must be able to meet one of the following availability requirements depending upon employment status: Obtain and maintain a current passport. For frequent US travelers, a second passport may be advisable to ensure that one passport is always available for use (if permitted by laws of the country in which the passport is held). Weekend travel will be required.