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Under general supervision of the Field Director, reviews assigned functions in Pathology and Clinical Laboratory Program throughout the United States and in some foreign countries. Provides general evaluation services, education, and consultation consistent with applicable Joint Commission standards, policies, and protocols. Determines the degree of compliance with applicable standards.
- 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.