The revised process for verifying facilities directors during survey

In a recent magazine article, it was mentioned that the Joint Commission was revising their process for reviewing credentials of facilities directors. A task, once performed by the clinical team, will now be a function of the Life Safety surveyor. Red E Services was curious about this “revised” process. We sat down with former Field Director for The Joint Commission, James Kendig, to discuss the significance of this revision.

Red E Services: Hello Mr. Kendig. Thank you for meeting with us. There has been a lot of concern about the revised process for verification of facilities directors and key roles. What are the key roles, aside from the facilities directors?

Mr. Kendig: Those roles are any that have requirements to assume that position. For example, anyone inspecting fire alarm systems would need to be NICET certified. Another example is someone that inspects fire doors. We all know that NFPA 80 states a qualified person shall inspect. If you are using in-house staff for that purpose, make sure you have documented proof of their qualification. This could simply be a note from the facilities director to HR that states a test was given to that person and that the person passed. HR would keep the letter and the test in the door inspector file. This is not new for the Life Safety surveyor.

Red E Services: Why the big push to revise the process for verification of the facilities director?

Mr. Kendig: The process was revised as a recommendation from CMS. They were not aware of clinicians validating facilities staff. As a component of the triennial accreditation with CMS, The Joint Commission revised who would be responsible and not the process of verification. The difference is, now HR folks will be visited by the clinical team and the life safety surveyor. Actually, we started this new process in the first quarter of 2024.

Red E Services: Why is it critical for hospital facilities directors to have job descriptions that match regulatory requirements?

Mr. Kendig: The hospital facilities director, whether in-house or contractor, plays a pivotal role in ensuring that the physical environment supports safe and effective patient care. They oversee infrastructure, compliance with life safety codes, emergency preparedness, and the management of utilities and facilities. Because their work impacts patient safety directly, their qualifications must align with the demands of the role. If the job description lists requirements such as a degree or certification, the HR file shall have those documents.

Red E Services: Would it make sense to state in the description that degrees and certificates are preferred, if not required?

Mr. Kendig: Yes. There are tremendously talented directors without a degree. It makes no sense to force the additional burden on someone that can demonstrate competency.

Red E Services: We have always viewed the person with years of experience as a merit that cannot always be matched by just a degree. However, many hospitals include certifications and degrees as mandatory, even if they aren’t strictly required. How do you view this practice?

Mr. Kendig: I say keep it simple. If an organization is using the description to recruit someone with a degree over someone with years of experience, they should list it as preferred. When drafting job descriptions, hospitals should differentiate between "required" and "preferred" qualifications. The Joint Commission evaluates compliance based on the actual responsibilities and qualifications necessary to perform the job effectively. Requiring certifications or degrees that are not mandated for the role can lead to challenges in recruitment and retention, especially in smaller or rural facilities. For instance, certifications like CHFM (Certified Healthcare Facility Manager) or advanced degrees may enhance a candidate's qualifications but should be listed as "preferred" unless truly essential.

Red E Services: Can you elaborate on the risks of overinflating job requirements?

Mr. Kendig: Certainly. Overstating requirements may inadvertently exclude competent candidates who have the necessary experience but lack a particular certification or degree. It can also increase scrutiny during Joint Commission surveys. If a job description lists a specific certification as "required," the hospital must demonstrate that the individual in the role possesses it. If not, it could lead to findings of non-compliance during an accreditation survey.

Red E Services: What advice do you have for hospitals when creating or updating job descriptions?

Mr. Kendig: First, review regulatory standards and state licensure requirements to ensure compliance. Then, identify the core skills and qualifications essential for the role. Certifications like CHFM or CHSP (Certified Healthcare Safety Professional) and degrees in engineering or healthcare administration are excellent assets, but they should only be mandatory if the role truly requires them. Use clear, concise language to differentiate between "required" and "preferred" qualifications, and regularly review job descriptions to keep them up to date.

Red E Services: Mr. Kendig, we appreciate your time and knowledge on this topic. For those hospitals struggling with creating an appropriate job description or qualifying their staff, let us know and we can assist you.