Sep 23, 2022

Life Safety Code Surveyor

  • Accreditation Association for Ambulatory Health Care | AAAHC
  • Travel Required
Part-Time Health Care

Job Description

The AAAHC Surveyor conducts detailed and complex accreditation surveys in ambulatory health care settings, including but not limited to ambulatory surgery centers, community health centers, medical and dental group practices, managed care organizations, and student health centers. Surveyors. Key surveyor responsibilities include:

  • Travel to client site(s) to perform thorough onsite surveys to assess compliance with applicable regulations and AAAHC Standards.
  • Serve solo or collaborate with one or more Surveyors on team surveys, closely interact with clients while onsite, and with AAAHC staff throughout the survey process.
  • Prepare reports of assigned onsite and virtual surveys, and evaluate client plans of correction relating to deficiencies cited. 
  • Conduct investigations of complaints, collect and prepare evaluative data and document results which may include evidence for use in adverse actions against non-compliant facilities. 

As a condition of employment/hire, AAAHC requires Surveyors to be COVID-19 vaccinated and comply with CDC-recommended booster shots, unless the Surveyor is granted an exemption in accordance with applicable laws. All Surveyors are required to strictly adhere to all AAAHC COVID-19 safety protocols and other infection prevention measures.

  • Complete required annual curriculum to achieve and maintain up-to-date knowledge of AAAHC Standards and competence in conducting surveys in Primary Care, Surgical/Procedural, and/or Health Plans, or Life Safety Code. Curriculum includes both in person and virtual training program participation. Annual maintenance curriculum varies depending on the survey/client eligibility (i.e., badges) achieved. On average, ongoing maintenance requires less than five hours per year and is achieved through webinars and eLearning completion, plus a biennial in-person Surveyor training and networking event. New Surveyor curriculum includes 1.5 days of live training in addition to approximately 10 hours of self-paced/virtual education.
  • Aligned with training curriculum and within the timeline required (varies; typically 3-6 months), gain “on the job” Surveyor experience through serving as an onsite Surveyor Observer Trainee and Surveyor Participant Trainee (initial training survey requirement: 2-3 surveys) to achieve eligibility (badges) to conduct surveys for different programs, survey types, client groups, and specialty services as well as in different capacities (e.g., roles; Participant, Solo, Team Leader). Survey badges address the variety of survey complexities and key client needs and require ongoing demonstration of competency through survey performance.
  • Achieve Surveyor Participant level badging including completion of curriculum and participation in required onsite training surveys within eight months of hire. While initially serving in a Surveyor Participant role alongside other Surveyors within a specified core track (i.e., Primary Care, Surgical/Procedural, and/or Health Plans, or Life Safety Code), within 24 months of hire, all Surveyors are expected to achieve Surveyor Solo status in order to conduct entire surveys by themselves.
  • Once fully trained in a core track, conduct a minimum of three surveys per year to maintain and demonstrate competency. Each onsite survey averages two days plus time for survey preparation, travel to/from client location, post-survey reporting (including peer evaluations for team survey participants), and travel expense reimbursement form completion. Time required for pre-survey preparation and post-survey activities varies based on survey and client complexity, program, client performance, and other factors with total time averaging 14 hours.
  • Comply with Surveyor policies including:
    1. Conduct initial onsite survey training (two surveys with a Team Lead/Mentor) within eight months of completing required Surveyor core track curriculum (i.e., Primary Care, Surgical/Procedural, Health Plans, Life Safety Code). 
    2. Review all client information (“Survey Materials”), structure survey approach consistent with AAAHC protocols, ensure understanding of relevant Standards in preparation for survey, make travel arrangements in accordance with AAAHC policies, and as appropriate, contact client primary contact and fellow survey team members to align travel schedules and survey approach expectations.
    3. Conduct a thorough survey including delivering a comprehensive client summation session in compliance with AAAHC requirements. Throughout the survey and during the summation session, engage with client organization staff to discuss AAAHC compliance requirements, positive compliance and quality improvement observations, Standards-based deficiencies, potential system vulnerabilities, and related patient and employee safety risk factors.
    4. In addition to providing professional, useful feedback on deficiencies cited, provide clients with consultative, educational feedback to guide their quality improvement and corrective action journey.
    5. Complete and submit survey report within two days (Participant)/four days (Solo, Team Lead) following the last day of survey that accurately and professionally documents survey observations, compliance deficiencies, and consultative feedback in accordance with AAAHC requirements.
    6. Provide timely response to AAAHC staff questions/requests for clarification regarding survey report and sufficiency of client plans of correction.
    7. Strictly adhere to AAAHC Surveyor conflict of interest disclosure policies and code of conduct that prohibits any behavior or activities that may bias or suggest a perceived bias in survey completion.
    8. All AAAHC Surveyors are prohibited from conducting activity on behalf of, or entering into any arrangement or agreement with, any other accreditation organization or any other entity conducting activities competitive with the activities of AAAHC.
  • Effectively utilize the AAAHC Accreditation (AMS) and Learning (LMS) Management Systems to complete required curriculums, maintain Surveyor availability calendar and profile, accept/decline offered surveys, access client information, complete and submit reports, respond to AAAHC staff questions/clarifications, and follow up on other tasks associated with the Surveyor role.

Occupations

Surveying

States

AL, AK, AZ, AR, CA, CO, CT, DE, DC, FL, GA, GU, HI, ID, IL, IN, IA, KS, KY, LA, ME, MD, MA, MI, MN, MS, MO, MT, NE, NV, NH, NJ, NM, NY, NC, ND, OH, OK, OR, PA, PR, RI, SC, SD, TN, TX, UT, VT, VI, VA, WA, WV, WI, WY

Security Clearance

NO Security Clearance

Job Requirements

Surveyors - Life Safety Code

  • Minimum of eight years hospital experience in engineering or safety management (e.g., mechanical, electrical, civil, biomedical, safety officer, or occupational safety and health specialist), including at least five years in a management position
  • Knowledge of Environment of Care Standards including Life Safety Code (NFPA101) and experience with a minimum of two accreditation surveys 
  • Specialized knowledge of building systems, utility systems, and fire protection systems (i.e., smoke detection and sprinklers)
  • 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 and committed to attain within one year of hire

 

Additional Qualifications for Non-LSC Surveyors Candidates

  • Must be an actively practicing health care professional employed or privileged by an ambulatory health care organization
  • Must have current or prior direct involvement with the accreditation process preferably in an AAAHC-accredited ambulatory health care organization

 

Qualifications for All Surveyors Candidates

  • Strong interpersonal, communication and problem-solving skills; expert ability to interview a diverse group of individuals. Concise writing skills. Ability to communicate (verbally and in writing) complex subjects effectively
  • Cognitive capabilities that include reading and processing complex organizational documents prior to and during an accreditation survey and scoring organization compliance performance against established AAAHC Standards and rating requirements. Ability to understand and interpret complex Standards
  • Organized, attentive to details, able to multi-task and effective time management skills
  • One reference from a currently active AAAHC surveyor
  • Experience in organizations that provide a variety of health care services across multiple settings is preferred
  • Computer Skills and Usage Required: Surveyors must have their own laptop computer and be proficient in its use. Surveyors must maintain continuous access to email as the primary source of communication with AAAHC. Note Surveyors are required to complete all survey reporting electronically through the AAAHC AMS, and participate in ongoing surveyor education including webinars and eLearning and assessments through the AAAHC LMS

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