Life Safety Code Surveyor

Join Our Mission to Elevate Ambulatory Health Care

At AAAHC, we are more than just a team; we are at the forefront of improving health care quality through accreditation. Our employees are the heartbeat of our mission-based culture, dedicated to applying their diverse skill sets—technical, research, clinical, analytical, and data-driven—to improve health care quality through accreditation. As we celebrate over four decades of excellence, we invite you to become part of our story. Here, your work is not just a job; it’s a journey filled with opportunities to learn, grow, and contribute to a higher purpose. Embrace the chance to be part of a community that values quality every day and strives for excellence in ambulatory health care.

Position Summary

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. Key Surveyor responsibilities include:

• In advance of assigned survey, review client information and prepare for onsite.
• Travel to client site(s) to perform thorough onsite surveys to assess compliance with applicable regulations and AAAHC Standards.
• Survey 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.

Position Description

• 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 an annual or biennial in‐person Surveyor training and networking event. New Surveyor curriculum includes 2.5 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 Lead). Surveyor 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 to conduct entire surveys by themselves.
• Once fully trained in a core track, Surveyors conduct a minimum number of surveys per year as determined by AAAHC to maintain and demonstrate competency. Each onsite survey averages 1.5 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.
• Maintain an up‐to‐date calendar through the AAAHC 1095 Engage Accreditation Management System (AMS) indicating dates for which the Surveyor is not available to conduct surveys during at minimum for the next six‐month period.
• Comply with Surveyor policies including:
  • 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).
  • 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.
  • 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.
  • 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.
  • Complete and submit Preliminary survey report within 24 hours (Participant, Solo)/48 hours (Team Lead) following the last day of survey that includes Standards ratings for all curated and onsite added Standards to provide clients an early indication of performance and potential Plan of Correction submission requirements.
  • 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.
  • Provide timely responses to AAAHC staff questions/requests for clarification regarding survey report and sufficiency of client plans of correction.
  • 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.
  • 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 1095 Engage and Learning Management System (LMS) to complete required curricula, 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.

Minimum Qualifications and Surveyor Competencies Required

• 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 and 1095 Engage as the primary source of communication with AAAHC. Note: Surveyors are required to complete all survey reporting electronically through 1095 Engage, and participate in ongoing surveyor education including webinars and eLearning, and assessments through the AAAHC LMS
• Must be an actively practicing health care professional employed or privileged by an ambulatory health care organization (may not apply to Life Safety Code professionals).
• Must have current or prior direct involvement with the accreditation process preferably in an AAAHC-accredited ambulatory health care organization (may not apply to Life Safety Code professionals). 

Life Safety Code Surveyor 

• Minimum of eight years hospital or healthcare facility experience in engineering or safety management (e.g., mechanical, electrical, civil, biomedical, safety officer, or occupational safety and health specialist); at least five years in a management position preferred
• Knowledge of Environment of Care Standards including Life Safety Code (NFPA101). Experience with a minimum of two accreditation surveys strongly preferred
• 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)] 

Travel Requirements

• Surveyors are required to travel for every onsite survey conducted 
• Surveyors are required to make their own travel arrangements including airfare, hotel and/or car rentals, using the AAAHC contracted travel service and preferred vendors where specified, and to comply with AAAHC Travel and Expense policies 
• Surveyors are occasionally required to attend webinars, conference calls, and education events in the evening and/or on weekends

Physical Requirements

Physical requirements of the Surveyor listed here are not exhaustive. Job‐related physical requirements may be added as needed.

• Routinely required to use hands to handle or feel objects, tools, or controls.
• Required to stand, walk, sit, and reach with hands and arms
• Required to raise arms above shoulder to reach and maneuver object.
• Required to climb or balance, and stoop, kneel, crouch, or bend as needed
• Occasionally required to lift (<25 pounds)
• Required to visually inspect and assess areas within and surrounding facilities on every survey
• Routinely required to read small print such as that found on medication vials, consent forms, maintenance logs, etc

Must be able to complete all aspects of the onsite survey safely