RSSAuthor Archive for Jackie Zagami

Jackie Zagami

Jaclyn Beck is the associate director of the Association for Healthcare Accreditation Professionals (AHAP) where she manages AHAP Accreditation Connection, the annual AHAP conference, and contributes to the monthly publication Briefings on The Joint Commission.

Proposed requirements for Behavioral Health Home certification product

The Joint Commission is developing an optional Behavior Health Home Care certification product focused on integration and coordination of behavioral and physical health care with the goal of improving individual’s outcomes, and is seeking input from the field on proposed requirements.

Organizations seeking this certification must be accredited under the Behavioral Health Care program.

To read more about this standard field review, visit The Joint Commission website.


New job openings

Hello AHAP members,

We’ve received a couple job openings and have been asked if we could share them with the membership in case anyone was interested in pursuing either of them. Please feel free to share amongst your colleagues. Contact information is at the end of the details below.

Job posting #1

Accreditation Manager – Presence Saint Joseph Medical Center, Joliet, Illinois

Lead and manage all aspects of accreditation readiness and regulatory compliance according to the Centers for Medicare and Medicaid Services (CMS), the Illinois Department of Public Health (IDPH), and The Joint Commission.  Provide strategic and tactical guidance to leaders and staff on accreditation readiness and educate personnel about accreditation requirements, implications and changes. Promote coordination and continuous integration of all performance and process improvement initiatives in collaboration with leaders. Coordinate, monitor and provide status report of all Meaningful Use objective measures related to the demonstration of compliance to CMS and other payers. Collaborate with leadership to identify and implement solutions for compliance challenges. Serve as Chair, Hospital Policy and Procedure Committee.

Education and/or Experience

  • Bachelor Degree in business or health care administration
  • 2 years of hospital clinical experience in quality improvement or experience with regulatory agency standards compliance including 2 years project management experience


  • Master’s degree nursing or health care administration or related field
  • Experience with managing and supporting organizational accreditation preparation
  • Business or office automation experience utilizing the principles and practices of health care quality management

For information please contact


Job posting #2

Manager of Accreditation- Western, NC

Responsible for the administration and oversight of all activities concerning the achievement of continuous regulatory and quality excellence and survey readiness for large acute care hospital.  The position is responsible for strategic and operational implementation of regulatory requirements, guidelines, and standards, and provides leadership and mentorship for collaborative team relationships in achieving continuous excellence.  Working closely with the quality and safety department and all levels of management, this position supports the facilitation, development, and implementation of outcomes through process improvement activities. The position monitors to ensure the medical staff, management, and staff are in a state of continuous compliance with the rules and regulations of regulatory agencies and that hospital policies and procedures are consistently followed.

Education and/or Experience

  • Bachelor’s Degree required
  • Five years management experience

For more information please contact

Coming soon: Forms and tools library to the AHAP website

AHAP is gathering tried-and-tested tracers, policies, and education/training materials for the upcoming launch of our new membership benefit: a library full of sample forms and tools to help you with your survey readiness needs.

If you have a helpful survey readiness tool, sample policy, or form that you would like to submit to the Association of Healthcare Accreditation Professionals (AHAP), please email associate director Jaclyn Zagami at

Soon, AHAP members will be able to download and use these tested tools and forms developed by your accreditation colleagues. Accreditation expert volunteers will ensure the compliance and effectiveness of materials, and new policies, tracers, and education materials will be added regularly, saving you time and effort.

Also, note that these forms will be posted to the AHAP website to be shared among the AHAP membership, but credit to the original developer will be required for use.

January issue of AHAP Insider available for download

AHAP members- the latest issue of the AHAP Insider, our quarterly association journal is now available for download. Inside you’ll find the results of our latest benchmarking survey on defining the role of survey coordinators, a Q&A on evaluating RFIs, and a Meet a Member featuring an active advisory board member who has recently retired from her 35-year career as a director of accreditation.

Click here to download.

AHAP 2013: We’re betting on red

What can we say, we like our odds! That’s why we’re headed back to Las Vegas for the 2013 Seventh Annual AHAP conference, June 6-7, 2013 at the Flamingo Las Vegas Casino and Hotel.

For the second time we are offering our Accreditation Specialist Boot Camp as a pre-conference event to help get new accreditation professionals started on the right foot. Spend two-and-a-half days at the Boot Camp— a unique classroom-based learning experience that delivers detailed descriptions, analysis, and training of all Joint Commission and CMS standards— and end your week building your professional network at the 7th annual AHAP conference.

As usual, we will award the 2013 Accreditation Professional of the Year and the Best New Accreditation Professional. We’re also bringing back our popular poster session, and a Day 1 roundtable discussion with our speakers and top accrediting bodies.

What type of sessions will you find at the conference? Here’s a sample:

  • A session on staying organized and keeping up with the ever changing Joint Commission and CMS standards requirements
  • A session on improving focus areas and reviewing regulatory changes and top RFIs for 2013
  • A session presented by a Life Safety expert focusing on Environment of Care and Life Safety management, and the documentation that accreditation professionals never get to see
  • Sessions on tracers and managing the mock survey process to prioritize improvements and correct vulnerabilities
  • A presentation by The Joint Commission on the challenging balancing act of managing risk is healthcare organizations
  • Sessions on performance improvement and managing CMS QAPI requirements
  • A case study presented by a director of accreditation who successfully completed the process of achieving advanced comprehensive stroke certification
  • Sessions on continual compliance staff training, education, and competency
  • And more!

We owe a great deal of gratitude to those who made the 2012 conference such a wonderful experience for us and attendees alike, including Jean Clark, Jodi Eisenberg, Greg Finch, Brad Keyes, Dana Moore, Candy Bright, Suzanne Richards, Sharon Chaput, Kirk Woodring, John Finnerty, and Gaye Hay.

Click here to view more information and registration details. If you have any questions about the 2013 conference, please don’t hesitate to contact me at I hope to see you all in Vegas!

Join us on the podium for the 2013 AHAP conference!

We are currently seeking speakers to present at the seventh annual AHAP Conference to be held June 6-7, 2013 at the Flamingo Las Vegas Casino & Hotel in Las Vegas.

We seek speakers to present on all aspects of hospital accreditation and encourage case studies of successful programs.

Here is a list of additional topics that would make great conference sessions:

  • Statistics and data management
  • Maximizing your risk assessment to eliminate TJC and CMS vulnerabilities
  • Career ladder for accreditation professionals: Motivation and recruitment strategies

If you don’t see your hot topic here, please write and let us know what expertise you can bring to the podium.

Click this link, complete the form, and submit it to us no later than January 23rd. Please be sure to include a brief description of your suggested session topic.

We look forward to hearing from you! If you’d like more information or wish to discuss a speaking topic before applying, please e-mail me at and we’ll set up a convenient time to speak by phone.

Q&A: The mechanics of a clarification

Q: Do you have any advice on how to format evidence for a clarification or choosing a sampling method to submit to The Joint Commission?

A: Note the following excerpted example that uses an audit submitted for a clarification by a client. It is very clear how the medical records were sampled during the audit process and it leaves no doubt as to potential bias or skewing of the data or the validity of the outcome. Of course, the data would also be submitted to support the claim. This submission leaves a perception of confidence in the organization’s ability to correctly assess and support its claim of compliance.

Sampling method: The hospital discharged more than 2,000 patients in the 30 days preceding the survey; a sample of 70 medical records was anticipated. A list of the 2,443 patients admitted on or after January 6, 2011 (30 days prior to the beginning of the survey), and discharged on or before February 4, 2011 (the day before the survey), was prepared. Every 80th patient on the list was selected for review. Nine of these records were arbitrarily omitted from the sample prior to the review, leaving 71 records in the final sample.

Calculation: The organization’s policy titled “Consents, Policy 440-34” adopted by the medical staff in June 1999 and last modified in September 2009 requires that the provider performing a high-risk procedure document informed consent either by signing the consent form or by documenting informed consent in the medical record. The policy also requires that the name of the person performing the procedure be recorded on the consent form.

The denominator for this calculation was the number of times informed consent was required by hospital policy. The numerator was the number of such occurrences where a) informed consent was documented as required by hospital policy and b) the name of the person performing the procedure was on the consent form.

Outcome: Overall performance within this sample was 97%, leading to a score of full compliance for this EP.

We respectfully request that this finding be removed based on the evidence presented.

This is an excerpt from The Joint Commission Survey Coordinator’s Handbook, 13th edition.

Editor’s Note: Do you have a question about clarifying RFIs, policy management, or survey-prep for our experts? E-mail your queries to Jaclyn Zagami at and receive one-on-one advice from our experienced advisory board. Submit a question and our credible sources will provide you with a timely answer.

Mandatory flu shots for RI healthcare workers

Rhode Island became the first state in the U.S. to adopt a flu immunization requirement for all healthcare workers, students, trainees, and volunteers who may have direct contact with patients. The Rhode Island Department of Health announced that the new amendments to its Rules and Regulations for Immunization and Testing for Healthcare Workers will go into effect by December 15. Healthcare workers may obtain a medical exemption if they have a medical reason for not receiving a flu shot; this exemption must be renewed annually by December 15.

Healthcare workers who are not medically exempt but are opposed to having a flu shot must submit a statement on their refusal by December 15 each year. Those who refuse the shot must wear a surgical face mask for any direct patient contact that occurs at times when the facility determines that the flu is widespread. According to the Rhode Island Department of Health, the measure was put in place to protect patients from influenza and prevent the spread of the infection.


Joint Commission and AMA/PCPI hold summit to discuss treatment overuse

The Joint Commission and the American Medical Association (AMA)-convened Physician Consortium for Performance Improvement (PCPI) held the National Summit for Overuse last week to discuss strategies to improve patient care quality and minimize overuse of certain treatments such as:

  • Heart vessel stents
  • Blood transfusions
  • Ear tubes
  • Antibiotics for the common cold
  • Early scheduled births without medical need

Podcasts highlighting the events can be accessed here.

Visit The Joint Commission website to read more about the National Summit for Overuse and strategies for appropriate use.

It only takes a minute (OK, maybe a minute and a half…)

As we continue to peel back the layers of the (green) onion that is fire alarm and suppression system testing documentation, I bring you this from the survey front: I can’t say that I find this consistently documented, which makes me think this is worth sharing with the group. By the way, for those of you who have not yet bitten the bullet, it may be time to extend your NFPA library beyond the Life Safety Code®. There are way too many pieces of the puzzle that live in the “other” codes for us to refrain for much longer (not that I am in any way endorsing any particular organization or product, but sometimes the way forward becomes impossibly clear…).

And so, turning to the testing of the emergency services notification transmission equipment (the equipment that comes into play when one must summon assistance from local/regional emergency responders), for this particular sequence of events, there is a requirement under NFPA 72, 1999 edition, 7-2.2 that indicates the receipt of the signal at the supervising station within 90 seconds shall be verified.

Now, for those of you who utilize a central monitoring service (and who, hopefully, are documenting each leg of that signal process – fire alarm system to central monitoring service; central monitoring service to the emergency responders) and, I suppose, those of you who ring directly through to the emergency responders – are you counting those precious seconds when you do your quarterly testing? If not, you would have to consider yourself a little bit vulnerable. Word to the wise.

Editor’s note: This blog post was written by Steve MacArthur, consultant for The Greeley Company, Danvers, MA, and taken from one of our sister blogs, Mac’s Safety Space. You can read the original post here.