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Joint Commission · 2 days ago

Reviewer-Orthopedic Disease Specific Care

Oakbrook Terrace, IL

Full-time

Onsite

Mid, Senior Level

$112K/yr - $112K/yr

5+ years exp

The Joint Commission is a health care organization that surveys and reviews health care organizations throughout the United States. They are seeking a Field Representative who will apply sophisticated analysis and communication skills to assess compliance with health care standards and identify opportunities for improvement.

Health Care

Responsibilities

Ability to analyze and synthesize survey/review findings to provide conclusions, recommendations and educational opportunities

Ability to connect 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 of 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

Educate 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 centered. 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, always 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

Qualification

CPHQ certificationJoint Commission standardsClinical experience in orthopedicsHealth care operationsPerformance improvement methodsInductive reasoningRisk assessmentAdvanced communication skillsTeam collaborationWritten communication skills

Required

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

Other health care practitioners must have an advanced degree (Master's or Doctorate) in their related field. (PA, OT, PT)

Clinicians performing any aspect of accreditation, certification, or verification reviews and surveys must have an active license, registration, and/or certification, as applicable to the, without any disciplinary action at the time of hire and throughout their employment with The Joint Commission

You must hold a CPHQ certification (Certified Professional in Healthcare Quality) through National Association for Healthcare Quality (NAHQ) at time of hire or attain by December 31, 2028

Five years of recent experience, including 3 years of direct clinical experience in orthopedics, and 2 years of accreditation or certification leadership or senior management experience

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

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

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

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

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

Must be available as required by the 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