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:
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.
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.
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.
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.
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.
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.
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.
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.
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.
Provide regular and timely attendance.
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.
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.
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.
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, and provide recommendations for improvement.
- Serve on corporate committees, such as the Surveyor Advisory Committee.
- Perform team leader responsibilities when designated as team leader.
- Serve as faculty for field representative education and/or field education programs.
- Conduct surveys and reviews in all accreditation/certification programs, across all settings.
- Serve as a preceptor for field representatives and adheres to the behavioral objectives in the course agreement.
- Serve as mentor for on-going field representative development.
Qualifications
KNOWLEDGE, SKILLS, CREDENTIALS AND ABILITIES: Field Representatives must have the following essential knowledge, credentials, characteristics and abilities:
Education:
Physicians must have a degree of Doctor of Medicine (M.D.) or Doctor of Osteopathy (D.O.).
Nurses must have graduated from an approved school of nursing and have a Master's degree in an appropriate discipline.
Administrators must have a Master's degree in a health-related field.
Medical Technologists must have a Master's degree in a related discipline.
Pharmacists must have a Doctor of Pharmacy degree (Pharm.D.) or equivalent.
Respiratory Care Practitioners must have a Bachelor's degree; a Master's degree in a related discipline is preferred.
Social Workers must have a Master's Degree in Social Work.
Psychologists must have a Psy.D. or Ph.D. in clinical psychology or a related psychological specialty.
Other health care practitioners must have an advanced degree (Master's or Doctorate) in their related field.
Certification/Licensure:
Current professional licensure in related disciplines is required (when required by law) at time of hire and throughout employment.
Physicians must be Board Certified at time of hire (see also "Specialized Knowledge and Experience" below for additional requirements for certain specialties, as applicable).
Applicants must have no disciplinary action relative to any current or previous professional license, provided such adverse action did not result solely from the applicant's health status.
Medical Technologists 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 accreditation or certification leadership or 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.
Experience in an accredited health care organization is preferred.
Experience, including direct involvement in healthcare accreditation surveys, required. Knowledge of Joint Commission standards and direct involvement with a minimum of two Joint Commission surveys preferred.
Critical Thinking Skills:
Ability to research, collect, organize, interpret and communicate a large volume of information from multiple sources (e.g., documentation, whether electronic or in hard copy, observation of methods, procedures and human behavior, interviews, etc.) to assess the degree of compliance with Joint Commission standards.
Ability to differentiate and assess the adequacy of alternative/innovative approaches to standards compliance, consistent with survey and review policies and protocols.
Ability to analyze and synthesize survey/review findings to provide conclusions, recommendations and educational opportunities.
Ability to connect findings, observations and interviews into a comprehensive analysis of the organization's care delivery systems.
Interpersonal Skills:
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.
Superior listening skills, including being able to detect, and be attentive and responsive to verbal and nonverbal communication cues.
Ability to work with diverse stakeholders and customers, including those that require multi-cultural sensitivity.
Problem Solving Skills:
Independent decision-making skills to direct and effectively manage the survey and review processes in a timely manner.
Ability to objectively assess organization performance.
Ability to openly discuss and resolve conflicts/controversy.
Judgment and ability to seek assistance when appropriate to make decisions, resolve conflicts, and/or achieve consensus.
Interviewing Skills:
Judgment and ability to elicit information through sensitive, appropriate use of open-ended questions and active listening.
Judgment and ability to explore information through effective use of follow-up questioning.
Ability to use interpersonal skills to effectively elicit information, even from interviewees whose views, ideas or procedures are unusual, disliked, incorrect or inappropriate.
Teamwork Skills:
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.
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, communications 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 take accurate and comprehensive notes and to produce timely reports and other documents required by each survey and review.
Ability to make presentations and produce written materials that are accurate, clear, concise, complete, well organized, understandable by others, and responsive to the needs of the customer.
Ability to use current survey and review technologies, research and surveyor tools and applications.
Physical Abilities:
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 able to engage in extensive travel as set forth above, including driving a car to remote locations, flying on small airplanes and into small airports, traveling in all types of weather conditions, etc.
Must be able to work in settings in which dust, allergens, and infectious diseases are present.
Availability:
Participates in all on-line, webinar and face-to-face training including New Field Representative Orientation on-site at Central Office as required.
Completion of up to six surveys with a preceptor in order to demonstrate an understanding of the Joint Commission's standards and their interpretation, survey and review processes, survey and review technologies, presentation techniques, general policies and procedures, and organization structure.
Ongoing participation in continuing education activities, including those sponsored by the Joint Commission, (e.g., conferences, in-person meetings, teleconferences, self-directed learning activities, distance learning programs, and special conferences).
Must be available as required by the particular demands of any applicable employment status, whether full-time, part-time, or intermittent, which standards are subject to change from time to time.
Weekend travel, when required by assignments or situations.
Specialized Knowledge and Experience:
Field Representatives in the Hospital Accreditation Program 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). Additional experience in other health care settings is preferred.
Medical Technologists must have experience working in 3 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.
Administrators in long-term care must have a minimum of 5 years' experience as a long-term care facility administrator or progressive clinical leadership and have a Nursing Home Administrator license (NHA).
Nurses in long-term care must have a minimum of 5 years' experience of progressive organization-wide long-term care nursing leadership. A Nursing Home Administrator license (NHA) is preferred. Additional background in hospital nursing leadership is desirable.
Field Representatives in the Ambulatory program must have at least 5 years' experience in an ambulatory care setting. Experience in organizations having multiple services and multiple settings is preferred.
Registered Respiratory Therapist Field Representatives must have 3-5 years' experience in home-care respiratory therapy or equivalent experience in sleep laboratories, and must have at least 2 years of management experience in one of these areas. Experience must include working for a home medical equipment provider with experience in a variety of durable medical equipment and oxygen delivery systems.
It is preferred that Field Representatives in home care also have recent experience in at least two programs (i.e., hospital, long-term care) or settings (i.e., hospice, private duty nursing, Medicare-certified agencies, or infusion therapy company).
Lead Radiologic Technologists, PET/CT Technologists, Radiology supervisor, Nuclear Medicine must be MNMT and/or ARRT(N), ARRT (CT) certified and possess a Bachelor’s degree.
Health and Medical Physicists should be masters prepared with a degree in medical physics or radiological sciences: PhD and Board certification preferred.
Field Representatives in Behavioral Health Care (BHC) must have experience in at least two BHC settings and two different age or disability populations.
Neurologists must be board certified at time of hire and throughout their employment as a Reviewer.
Reviewers must continue to be engaged outside of The Joint Commission in a clinical or teaching setting in the subject matter they are reviewing and must be able to provide evidence of such work upon request.
Cytology Retrospective Reviewers must have current certification as a Cytotechnologist or Clinical Laboratory Scientist with a nationally accredited laboratory science certification organization, such as ASCP, NCA, or equivalent. Reviewers must be currently enrolled and participate in CMS approved proficiency testing program for GYN cytology, either independently or with another employer. Reviewers must demonstrate proficiency testing status for GYN cytology at the time of hire, maintain acceptable proficiency testing status during Joint Commission employment and provide the proficiency testing result report to the Joint Commission within thirty (30) days receipt from the provider, and be certified in at least one automated cytology screening instrument at hire, which must be maintained.
Health Care Staffing Reviewers must have a Bachelor’s degree in a health-related field with 5 years of health care experience, including 2 years in a leadership position in healthcare staffing/registry services. Knowledge of clinical and allied staffing services required. Business management and operational experience in the industry required. Demonstrated knowledge of the HCSS industry including trends and staffing arrangements such as per diem, travel, temporary–to-permanent, etc.
PMB Physician Reviewers must meet one of the following criteria: Boarded in transfusion medicine; Have been the medical director of a patient blood management program; Have at least two (2) years' experience in a patient blood management program; Have held or currently holds the position of Transfusion Safety Officer or equivalent.
PMB Nurse Reviewers must meet one of the following criteria.Have at least two (2) years' experience in a patient blood management program; Have held or currently holds the position of Transfusion Safety Officer or equivalent.
PMB Medical Technologists must meet one of the following criteria:Be certified as a Specialist in Blood Bank (SBB), and; Have held or currently holds the position of Transfusion Safety Officer or equivalent.
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 due to business needs and/or reasonable accommodations for individuals with disabilities.
