at The Joint Commission in Oakbrook Terrace, Illinois, United States
Job Description
Overview
GENERAL SUMMARY:
The Life Safety Code Surveyor, with minimal immediate direction or supervision, reviews assigned functions in Life Safety, Environment of Care, and Emergency Management throughout the United States. Life Safety Code Surveyors apply sophisticated analysis skills and inductive reasoning skills to assess health care organizations’ compliance and to identify opportunities for improving compliance with applicable Joint Commission standards, policies, and protocols.
Responsibilities
ESSENTIAL JOB FUNCTIONS AND RESPONSIBILITIES:
A. PRINCIPAL DUTIES AND RESPONSIBILITIES: Life Safety Code Surveyors must be able to perform the following essential job duties and functions:
1. Learn, understand, retain, explain and objectively apply Joint Commission standards, including continual updating and retraining regarding Life Safety, Environment of Care, and Emergency Management standards and technologies.
2. Conduct a thorough and credible evaluation of assigned services that meet Life Safety, Environment of Care, and Emergency Management standards.
3. Plan, review and apportion survey time so that all survey requirements are addressed thoroughly on every survey.
4. Review and evaluate pre-survey information and conduct all pre-survey activities; research, collect, organize, and interpret information from multiple sources. This includes identifying and using organization-specific information based upon an evaluation of priority focus areas.
5. Conduct comprehensive interview facilities managers and other staff to determine level of compliance with standards.
6. Analyze documents, such as policies, procedures, testing documentation, safety committee meeting minutes, etc., to assess the level of compliance with Joint Commission standards, evidence of performance improvement, and safety and quality of care.
7. Using established survey protocols:
a. Analyze written self-descriptive program information.
Participate in and conduct relevant on-site activities, including without limitation inspections, required conferences, tours, and interviews.c. Analyze and interpret all data submitted by the organization.
d. Document all observations in a thorough, accurate manner utilizing applicable surveyor technology, providing adequate indication of non-compliance where appropriate.
e. Submit survey findings in a complete and accurate manner through WST and consult with the survey team leader as appropriate.
f. Interpret and explain the intent of the standards to the organization’s personnel in a detailed, constructive, sensitive, and professional manner. This often includes the ability to communicate negative information in a constructive manner.
g. Consult with the organization during survey concerning non-compliance, opportunities for improvement, and remedial action required. Recommends publications and other resources that clarify standards and/or demonstrate compliance with standards.
8. Maintain current knowledge of, apply and follow Joint Commission Life Safety, Environment of Care, and Emergency Management standards and requirements over which they have review responsibility, including without limitation:
9. Joint Commission policies and procedures to ensure that its mission is achieved;
10. Current federal regulations pertinent to the Environment of Care and Emergency Management standards;
11. LSC requirements; and
12. Relevant, contemporary knowledge in professional field of expertise.
13. Collaborate in a productive manner with colleagues to ensure that the mission of the Joint Commission is achieved, including conducting interactive evaluation sessions with staff and offering relevant consultation where improvement is needed.
14. Life Safety Code Surveyor are required to travel extensively, including travel on weekends, at all times of the day/night, and without prior notice, travel by automobile and on airplanes of all sizes, and travel in all weather conditions. This includes the ability to travel to all types of airports and in whatever type of ground transportation is necessary to enable timely performance of surveyor duties.
15. Ability to provide regular and timely attendance.
16. Complete all applicable administrative responsibilities, including accurate peer evaluations, educational and development programs.
17. Preparing for on-site review;
18. Interactions with Standards Interpretation Group; and
19. Presentations to Accreditation Committee as requested.
20. Follow customers’ safety policies when on site, including following requested safety measures ( e.g. , wearing appropriate protective clothing or equipment, limiting number and locations of ceiling tiles removed, etc.) provided that such policies are not in conflict with Joint Commission policies.
Qualifications
A. KNOWLEDGE, EXPERIENCE AND SKILLS REQUIRED :
1. Education:
a. Master’s degree in related field or equivalent level of education preferred.
Bachelor’s degree in related field.c. College degree must be from accredited institutions of higher learning.
2. Certification/Licensure/Registration: Current certification/licensure/registration in a field related to plant, technology, and safety management [i.e., Certified Healthcare Facility Manager (CHFM), Certified Healthcare Safety Professional (CHSP), Healthcare Environmental Manager (HEM), Certified Industrial Hygienist (CIH), Certified Safety Professional (CSP), Professional Engineer (PE)] or able to attain within one year of hire.
3. General Knowledge and Experience:
a. Eight years of hospital experience in facilities management, including at least five years in a management position in engineering, facilities management, hazardous materials and waste management, emergency preparedness, biomedical equipment, and/or utility systems as well as experience as the organization’s Safety Officer.
Knowledge of Joint Commission Environment of Care standards including the Life Safety Code (NFPA101), the Health Care Facilities Code (NFPA 99) and other relevant NFPA standards and direct involvement with a minimum of two Joint Commission surveys.4. Analytical Skills:
a. Ability to research, collect, organize, interpret, and communicate information from multiple sources (i.e., documentation, observation, interviews) to assess the degree of compliance with Joint Commission standards.
Ability to critically review and analyze performance measurement data.c. Ability to objectively assess organization performance.
d. Ability to differentiate and assess the adequacy of alternative/innovative approaches to standards compliance, consistent with survey policy and protocols.
e. Ability to analyze and synthesize survey findings to provide conclusions, recommendations, and educational opportunities.
5. Analytical Skills:
a. Ability to be sensitive to and respectful of all internal and external stakeholders and customers, without compromising in any way on the message that must be delivered.
Open to direction, inquiry and idea exchange.c. Superior listening skills, including being able to detect, attentive and responsive to verbal and nonverbal communication cues.
d. Ability to work with diverse stakeholders and customers, including multi-cultural sensitivity.
6. Interpersonal Skills:
a. Sensitive to and respectful of all internal and external customers.
Open to inquiry and exchange.c. Responsive to verbal and nonverbal communication cues.
d. Multi-cultural sensitivity.
7. Professionalism:
a. Behavior consistent with Joint Commission 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.c.
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