Policy / Procedures

Administrator Surveyor Participation Guidelines

Criteria for Recruiting (Pre-Requisites):

A candidate for the position of administrator surveyor shall meet the following eligibility criteria.

Education

1. A bachelor’s degree is required.
2. A graduate degree in hospital administration is preferred

Experience: (Normally exhibited by the following experience)

1. At least 5 years experience as the Chief Executive Officer or Chief Operating Officer of an HFAP accredited hospital; or
2. At least 5 years experience as an associate/assistant administrator with responsibilities for at least two or more of the following areas:
   • Nursing services,
   • Two other responsibilities among the following: pharmacy, dietary, physical rehabilitation therapy, respiratory therapy, housekeeping, physical plant,
   • Responsibilities regarding the governing board and medical staff committees, and interact directly with board and medical staff committee.
   • For associate/assistant administrators, or any position other than CEO, a recommendation from the CEO must be included.
3. Have experienced one or two HFAP surveys (two preferred)

Application Procedure and Processing:

1. Submit the following to the Chief Operating Officer (COO), Healthcare Facilities Accreditation Program (HFAP):
   • Letter of intent to become an HFAP Surveyor
   • Resume / curriculum vitae
   • Three letters of recommendation. It is preferred that one of these is a letter of support by a member of the governing body.
2. Agree to serve as a Federal witness, if requested
3. The HFAP COO will submit candidate resumes, applications, and letters of recommendation to the Bureau Healthcare Facilities Accreditation (BHFA) for review and approval. If approved by the Bureau, an appointment of “surveyor-in-training” will be awarded.
4. Appointment decisions are recorded in the minutes of the Bureau Healthcare Facilities Accreditation (BHFA) meeting.
5. The COO will notify the candidate of Bureau decisions. The COO will forward copies of the HFAP Surveyor Confidentiality Agreement and Business Agreement forms to the new appointee for signature. Upon receipt of the signed documents, surveyor-in-training assignments will be prepared.

Training Requirements:

1. Surveyors-in-Training are required to participate with at least two surveys as observer/surveyor-in-training.
2. As available, attend appropriate:
   • Training program
   • Workshop
3. Surveyors-in-training must receive satisfactory evaluations by two (2) surveyor trainers prior to being advanced as a full surveyor.
4. During year one, the new surveyor is expected to participate in:
   • Two surveys as an observer/surveyor-in-training followed with
   • Two surveys as a full surveyor.
5. Special education, training and experience is required for surveyors of the following freestanding services:
   • Behavioral/Mental Health
   • Ambulatory Care/Ambulatory Surgery
   • Physical Rehabilitation
   • Mental Health/Substance Abuse Centers

Reappointment Criteria:

Annually, the Bureau Healthcare Facilities Accreditation (BHFA) reappoints surveyors using the criteria (below).

1. Participates in four surveys per year.
2. Professionally conducts surveys
3. Maintains confidentiality of survey program materials, accreditation findings and decisions.
4. Advises HFAP staff immediately of any existing or potential conflicts of interest (such as former places of employment) related to survey of facilities for which they are scheduled, and precludes self from participation in such surveys unless approved to do so by the COO of the Healthcare Facilities Accreditation Program.
5. When conducting surveys, represents the HFAP only. No other business is conducted nor is any other business represented either expressed or implied.
6. Attends HFAP surveyor workshops, as provided
7. Represents the HFAP in a professional manner.
8. Satisfactory evaluations by surveyor trainer, surveyed facilities, and team members. (Effective November 2004)
9. Individuals, who are recently retired, within one year, may be reapproved if they continue to be actively involved in inspections and receive satisfactory evaluations regarding performance.
10. Reappointment decisions are recorded in the minutes of the Bureau of Healthcare Facilities Accreditation (BHFA) meeting.

Termination:

1. If a surveyor no longer wishes to continue in this role, the surveyor is asked to have a debriefing with the HFAP COO or designee.
2. If the surveyor makes the decision to resign, it is desirable that a four-month notice be provided. It is also desirable that the surveyor complete or find an alternative to any scheduled surveys.
3. Surveyors that receive unsatisfactory peer or facility evaluations will be counseled by the HFAP COO.
4. Surveyors will be terminated for:
   • Unprofessional or unethical behavior
   • Confidentiality breaches
   • Behaviors demonstrating conflicts of interest.

Personnel Files:

1. The Director of Accreditation Services, Healthcare Facilities Accreditation Program maintains a personnel file for each surveyor.
2. For each surveyor, the following documents will be maintained:
   • Curriculum vitae
   • Signed Surveyor Agreement
   • Letters of Reference
   • Signed Business Associate Agreement
   • Initial BHFA appointment letter
   • Attendance at education sessions
   • Post-training test scores and other competency validation documents
   • Evaluations, including letters of commendation, investigation of complaints and action taken, if required.
   • Other correspondence, information and/or materials related to their services as HFAP surveyors or consultants.

Developed: May 2001 Revision(s): October 2004, March 2007, May 2007, May 2008, February 2009.