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Surveys international health care organizations as assigned. Applies systems analysis skills and inductive reasoning skills to determine a health care organization’s 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.

Position Accountabilities:

• Conducts a thorough evaluation of international organizations that meet accreditation/certification eligibility criteria on-site or remotely. 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:

• 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

• 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:

• Participates in and/or conducts all required on-site and/or remote 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
• 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 score based on evaluation of the evidence
• Prepares an exit report for the organization

• 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 central office as needed.

• Maintains current knowledge of Joint Commission International standards, policies, and procedures. Maintains current knowledge in professional field of expertise. Demonstrates appropriate 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 completing expense reports, team evaluation tool, etc.

• Participates in evaluating the performance of the survey team after each survey by completing the Team Evaluation Tool, including 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 all required JCI staff development activities.

• May perform other duties as assigned, including, but not limited to:

• 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
• Serves as team leader when assigned to a team
• Serves as faculty for surveyor education and/or field education programs
• Receives training and conducts surveys across programs and settings onsite and/or remotely
• Serves as preceptor for surveyors in training

• If assigned the team leader role, responsibilities and duties also include the following as defined in the “JCI Accreditation Team Leader Role and Responsibilities” document. Also refer to the “Team Leader Job Description”.

• Contacts the organization to clarify any questions from the review of the application
• Develops an organization-specific agenda from the standard agenda template based on the information provided in the survey applications
• Maintains communications with the organization’s survey coordinator. Responds to special requests regarding the survey agenda and revises the agenda, as needed, prior to the start of the survey. Communicates any modified agenda information to the organization and each team member in a timely manner
• Coordinates travel, security/safety, and hotel accommodations for the team
• Coordinates Preliminary Survey Activities.
• Coordinates Survey Activities during the Survey
• Coordinates and finalizes the exit report
• Completes all required post-survey activities
• Serves as preceptor for surveyors
• Serves as mentor for on-going surveyor development

Education:

Accepted qualifications for surveyors with a non-clinical background, such as hospital administrators, is a bachelor’s degree required or level of knowledge and experience equivalent to that ordinarily acquired through completion of a master's degree in health care or a related field; master’s preferred.

Certification/Licensure (at time of hire and throughout employment):

• Current professional licensure in related disciplines is required (when required by law) at time of hire.
• Physicians must be Board Eligible or Board Certified or equivalent at time of hire.
• Applicants have no history of disciplinary action(s) relative to current or previous professional license, provided such adverse action did not result solely from an individual’s health status.
• Medical Technologists must be registered with a nationally accredited organization.
• Paramedics and EMTs must be registered with a nationally accredited organization.

General Knowledge and Experience:

• Five years of recent experience, including 3 years of direct clinical experience in the appropriate health care setting(s), 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 is preferred.

Specialized Knowledge and Experience:

• 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.
• Medical Technologists must have experience working in three or more technical specialties (i.e., chemistry, microbiology, blood bank) and experience in settings of multiple sizes, as well as at least 5 years of laboratory management experience.
• Hospital Administrators with the designation of FACHE (Fellow, American College of Healthcare Executives) are preferred.
• Clinical Care Program Certification program surveyors must have a minimum of 5 years’ experience of progressive clinical leadership and current knowledge or experience in the implementation of clinical practice guidelines, development and implementation of clinical pathways and in the identification and use of performance measures to improve clinical outcomes. Experience in chronic disease management is desirable.
• Medical Transport program surveyors must have at least five (5) years’ experience in emergency care as a paramedic, emergency medical technician, physician, or nurse and in dispatch or administration of a medical transport organization.

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 business writing in English is required, fluent in another language is preferred.

Physical Abilities:

• Must be able to lift/move/carry 25-50 pounds (i.e. luggage or supplies), sit and stand or remain in a stationary position for long periods of time, and walk or move lengthy distances in a variety of settings.
• Must be capable of extensive travel 100% of work time including but not limited to, flying for extended periods of time (i.e. over 10 hours of continuous flight in coach class), manage moving and sleeping across various time zones, positioning self on small airplanes and in small airports, and into all countries that Joint Commission International does business.
• Work and healthcare environments may include, but not limited it, exposure to dust, allergens, pollution, infectious diseases, hazardous materials, and noise.
• Must be able to observe and participate in work activities in real-time and without slowing or otherwise interrupting the progress. Work activities include operating a laptop or tablet as well as frequently communicating with large and small groups in person, via phone, or webinar.
• Must repetitively ascend/descend multiple flights of steps and ladders, stooping, squatting, adequately inspect and observe all medical facilities, equipment, and procedures.

Availability:

• Must be willing and able to travel to all countries where Joint Commission International accredits.
• 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:
• Full time (0.75 FTE) – available 52 weeks/year (vacation, personal, and holiday time)
• Part time (0.5 FTE) – 2 to 3 consecutive calendar weeks per month
• Obtain and maintain a current passport. Ability to obtain visas when applicable. 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.

This job description is intended to describe the general nature and level of work performed by an employee assigned to this position. The description is not an exhaustive list of all duties, responsibilities, knowledge, skills, and abilities, and working conditions associated with this position. All requirements are subject to possible modification and reasonably accommodate individuals with disabilities.