at The Joint Commission in Oakbrook Terrace, Illinois, United States
Job Description
Overview
GENERAL SUMMARY
Field Representatives, with minimal direction or supervision, survey and/or review health care organizations throughout the United States. Field Representatives apply sophisticated 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. Field Representatives to apply their knowledge to assess risk points in organizations. Field Representatives must have the credentials, professional demeanor and expertise to earn the respect of the health care organizations’ staff and leadership. They must be able to employ advanced communication skills to engage health care organization staff in interactive dialogues on a broad array of health care issues in order to assess compliance and to identify opportunities for improving compliance. Field Representatives must have superior written communication skills to prepare detailed, accurate management reports that clearly link individual standards deficiencies with potential systems vulnerabilities and related organization risk points. Field Representatives must be able to professionally and effectively communicate survey results to health care organization leadership in a constructive and collegial style. They must possess sound understanding of High Reliability, Robust Process Improvement and Culture of Safety. They must be able to effectively and efficiently utilize their time by employing RPI tools in their daily activities. Field Representatives must be able to work effectively and collaboratively as a team member. Field Representatives are also required to participate in other Joint Commission activities as assigned.
Responsibilities
ESSENTIAL JOB FUNCTIONS AND REQUIREMENTS
PRINCIPAL DUTIES AND RESPONSIBILITIES: Field Representatives must be able to perform the following essential job duties and functions:
1. Learn, understand, retain, explain and objectively apply Joint Commission standards, which includes continual updating and retraining about state-of-the-art care, processes and technologies that are approved by the Joint Commission’s Board of Commissioners.
2. Maintain current knowledge of, apply and follow:
+ Joint Commission policies and procedures to ensure that its mission is achieved;
+ Relevant, contemporary knowledge in professional field of expertise; and
+ Applicable regulations pertinent to the survey.
1. Exercise independent judgment to conduct a thorough evaluation of assigned services and programs that meet accreditation and certification eligibility criteria, including without limitation the following:
+ Review and evaluate pre-survey/pre-review information and conduct all pre-survey/pre-review activities. This includes using organization-specific information and selecting appropriate patient records to identify diverse patient populations, diagnoses and experiences.
+ Conduct a thorough analysis of risk to patients, staff and/or visits within care delivery systems
+ Thoroughly evaluate patient care environments to assess health care organizations’ operations and standards compliance.
+ Interview staff and patients to determine health care organizations’ level of compliance with Joint Commission standards.
+ Detect and interpret environmental cues of relevance to the evaluation of health care organizations’ operations and standards.
+ Conduct a thorough and credible evaluation of assigned services that meet life safety requirements, environment of care and emergency management standards, as necessitated by the type survey assignment.
+ Accurately place all identified risk points in/on the SAFER matrix.
1. In response to patient-centered evaluation activities, analyze policies, procedures, meeting minutes, clinical standards, protocols, patient records, employee records, committee reports, to assess the level of compliance with Joint Commission standards, implementation of policies, evidence of performance improvement, and quality and safety of care.
2. Using Joint Commission’s established survey/review process, exercise independent judgment and discretion as follows:
+ Participate in and conduct required on-site activities, including without limitation inspections, required conferences, tours and interviews with staff.
+ Review and interpret all data submitted by the organization.
+ Document observations in a thorough, accurate manner utilizing applicable survey technology. Uses MST application in real-time and finalizes reports in a timely manner each day.
+ Provide appropriate documentation to guide health care organization improvement activities, including a comprehensive rationale for any observations.
+ Link each observation to potential system-level vulnerabilities and opportunities for organizational improvements in patient care and safety.
+ Consult with the organization during surveys or reviews concerning potential risks to patients, staff and/or visitors when identified, clarify opportunities for improvement, and remedial action required.
+ Provide ample opportunity for discussion and clarification of potential findings to allow organizations to provide evidence of compliance or to reach an understanding of the organizational risk.
+ As appropriate, offer examples of best practices relating to identified opportunities for improvement, recommend publications and other Joint Commission resources that clarify standards and / or demonstrate compliance with standards.
+ Report survey/review findings in a complete, accurate, understandable, and timely manner.
1. Interpret and explain the intent of standards to each health care organization’s personnel in a detailed, constructive, professional manner, and audience-centred. This often includes the ability to communicate negative information in a constructive manner.
2. Exercise appropriate judgment to seek assistance from others, including Central Office, the Field Director on call, the program specific Field Director, the Standards Interpretation Group, or the Accreditation and Certification Operations leadership as appropriate.
3. Assist the Central Office in responding to standards interpretation questions from the field, analysis of periodic performance reviews, evidence of standards compliance reports, complaints, and Medicare out-of-compliance reports.
4. 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 on high-profile issues in health care and offering relevant consultation where improvement is needed.
5. Provide regular and timely attendance.
6. Travel extensively, including travel on weekends, at all times of the day/night, and sometimes without prior notice, travel by automobile and on airplanes of all sizes, and travel in all weather conditions. Field representatives must be able travel to all types of airports and in whatever type of ground transportation is necessary to enable them to timely perform their duties.
7. Follow customers’ 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 policies.
8. Complete all applicable administrative responsibilities, including:
+ Accurate peer evaluations;
+ Staff education and development programs;
+ Preparation for on-site survey/review;
+ Interactions with Standards Interpretation Group; and
+ Participation in meetings with and presentations to Accreditation Committee as requested.
1. 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 and review processes,
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