• Conducts a thorough and credible evaluation of assigned services that meet laboratory accreditation criteria. Plans, reviews and apportions review time so that all review requirements are addressed thoroughly. Reviews and evaluates pre-survey information; researches, collects, organizes, and interprets information from multiple sources. Interviews physicians and staff to determine level of compliance with standards. Analyzes documents, such as performance data, and use of clinical practice guidelines, to assess the level of compliance with Joint Commission standards, evidence of performance improvement, and quality of care.
• Using established review protocols:
• Analyzes written self-descriptive program information.
• Participates in and/or conducts all required conferences and interviews; analyzes all data submitted by the organization.
• Documents all recommendations, providing adequate indication of non-compliance.
• Submits review findings in a complete and accurate manner to the Clinical Laboratory Scientist Surveyor.
• Interprets and explains the intent of the standards to the organization’s personnel. Consults with the organization during review concerning non-compliance, opportunities for improvement, and remedial action required. Recommends publications and other resources that clarify standards and/or demonstrates compliance with standards.

Education

• Pathologist, Board Certified in Clinical and Anatomic Pathology

General Knowledge and Experience

• Five years of recent clinical experience, including at least two years in management, preferably laboratory, and two years demonstrated responsibility for oversight, decision-making, management, and improvement in histopathology and cytology.
• Demonstrated knowledge of pathology industry including trends, performance measurement, and improvement.
• Demonstrated knowledge of compliance requirements related to CLIA’88.
• Demonstrate general knowledge in areas of Anatomic and Clinical Pathology.

Analytical Skills

• Ability to research, collect, organize, interpret, and communicate information for 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.
• Ability to objectively assess organization performance.
• Ability to differentiate and assess the adequacy of alternative/innovative approaches to standards compliance, consistent with survey policy and protocols.
• Ability to analyze and synthesize survey findings to provide conclusions, recommendations, and educational opportunities.

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.