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.

Come check out our conference poster session

This year’s AHAP conference to be held May 10-11, 2012 in Orlando, FL features its first ever educational poster session, and we’d like to share the roster with you:

  • “Surveying the secret world of Surgical Services:  How to navigate a mock survey of surgical services in your facility” – Sandy Biga, RN, Alegent Health Midlands Hospital, Omaha, NE
  •  “The use of data mining with alerts to improve nurse documentation” – Sheila Belcher, BSN, RN, CSHA, Pikeville Medical Center, Pikeville, KY
  •  “One year, three surveys: Continuous readiness at Mayo Clinic” – Melanie Ryan, Mayo Clinic, Rochester, MN
  •  “Optimal practitioner on-boarding process” – Shelly G. Albrechtsen, Brookhaven Memorial Hospital Medical Center, Patchogue, NY
  • “Patient safety: Striving towards zero defects” – Jayme Gardner, RN, BSN, East Alabama Medical Center, Opelika, AL 
  •  “The path to regulatory readiness”- Pat Caruso, RN, BSN, CNML, Bristol Hospital, Bristol, CT
  • “Developing a low-cost solution to a high risk problem: Transforming the process of care to reduce central line associated blood stream infections” – John Finnerty, RN, BSHA, CSHA, Nassau University Medical Center, East Meadow, NY
  •  “Using a single checklist/signature sheet at initial and reappointment” – Mary Johnson, CPCS, CPMSM, and Pearl Forsyth, Saint Luke’s East Hospital, St. Louis
  •  “Fire rated wall penetration and Joint Commission Life Safety Code® compliance” – Kevin Jones, University of Utah Health Care, Salt Lake City
  • “Involving the executive team in survey readiness” – Lynda Bailey, RN, BSN, University of Utah Health Care, Salt Lake City
  • “The Onion Efffect” – Megan Lough, Scripps Centralized Credentialing, San Diego
  • “Regulatory Readiness: Tools for a successful CMS survey” – Candy Bright, RN, BSN, Village Hospital, Greer, SC

    Don't miss this one-of-a-kind educational event!

You won’t want to miss this opportunity to gain knowledge and share best practices, so if you still haven’t registered, make sure to sign up this week to receive $100 off the conference price (just use source code ET106724at checkout).

Visit our conference webpage for more information.

Two new reasons to go to the AHAP conference

This year’s AHAP conference, to be held May 10-11 at the Hilton at Walt Disney World® Resort in Lake Buena Vista (Orlando), FL is sure to be a valuable and educational networking resource for you, and we’re happy to announce that we have two more reasons why:

Reason #1-We’re offering a registration discount. And who doesn’t love a discount? We’re offering $100 off conference registration for the entire month of April. Just be sure to use source code ET106724 at checkout to save $100!

Reason #2- We’ve added a new breakout session to Day 2 of the conference titled Regulatory readiness: Tools for a successful CMS survey*, presented by Candy Bright, RN, BSN. Ms. Bright is the safety and regulatory manager at Village Hospital in Greer, SC, and her case study will give you easy and effective strategies to implementing a CMS survey readiness program, assessing organizational survey readiness, and creating interdisciplinary teams to improve CMS compliance and staff participation.

*This breakout session will replace the breakout session titled “Understanding hospital recognition programs for optimal cardiovascular and stroke care”.

Visit our conference webpage to find additional information about the agenda, CE credits, learning objectives, and more.

We want your survey bloopers

Has a Joint Commission surveyor ever called you by the wrong name? Did you accidentally fumble your words while presenting the findings of your mock tracer to leadership? Or maybe you answered a series of survey questions perfectly only to find out you had a huge piece of spinach in your teeth the whole time.

We want to hear about it! If you have a funny or awkward story to tell involving a surveyor or survey prep activity that you’d like to share with your peers, please e-mail associate director Jackie Beck at with your story. We’ll feature the collection of stories in our next issue of the AHAP Insider, a quarterly membership journal published exclusively for AHAP members.

It is our promise that your stories will be 100% anonymous.

Accreditation Professional of the Year awards

Do you have a colleague who helped launch a successful accreditation program in your hospital? Or who made significant contributions to improve survey-readiness in the field in general? Do you know a dedicated accreditation professional who makes a difference in the profession? Or an accreditation professional who is new to the role and has already demonstrated effective survey readiness?

I’m happy to announce that we are now accepting nominations for the first ever Accreditation Professional of the Year awards. The Accreditation Professional of the Year awards were created by AHAP in an effort to recognize and celebrate survey coordinators and accreditation professionals who have made tangible improvements to the survey prep process in their facilities, and have demonstrated excellence in leadership, teamwork, and regulatory expertise.

The awards are broken down into two categories— Accreditation Professional of the Year (similar to the lifetime achievement award) and Best New Accreditation Professional— and the winners of this year’s awards will be selected by our board and presented at the AHAP conference in May.

The nomination form and more information on eligibility can be found here:

Feel free to share this with your staff and your colleagues, and if you know someone who fits the bill for either of these two awards, please consider nominating them.  We would love to recognize them for all of the hard work they’ve done at your facility and in the regulatory field, and we can’t wait to introduce you to the 2012 Accreditation Professional of the Year and the Best New Accreditation Professional in Orlando in May.

Education and fun rolled into one

We know there are limited educational resources out there for accreditation professionals to swap best-practices and network with their peers. And that’s why we could not be more excited about this year’s AHAP conference, coming up in just a few months.

The 6th Annual AHAP Conference, to be held May 10-11, 2012 at the Hilton at Walt Disney World® Resort in Lake Buena Vista (Orlando), FL, is a multi-source, educational experience that will provide accreditation professionals and survey coordinators with the following resources:

  • Top Joint Commission findings for 2011 and regulatory changes for 2012
  • Leading experts in Life Safety,  Data Management, and Suicide Risk Assessment compliance
  • Opportunities to talk with representatives from The Joint Commission, DNV, and HFAP
  • Peer networking opportunities
  • Eleven hours of continuing education for ANCC, CSHA, and NAHQ credits
  • And much more!

You can view the complete agenda, learning objectives, and registration details here.

If you’re interested in presenting a poster at this year’s conference, please download our poster application form, complete it, and e-mail it to AHAP Associate Director Jaclyn Beck at Accepted poster presenters will receive a 50% discount off the price of conference admission. We are interested in innovative strategies that have been implemented in hospitals to improve survey-readiness, staff involvement, and patient and staff safety.

Will we see you there? Leave your comments here.


6th annual AHAP conference speaker lineup

And what a lineup it is! We’re so proud of our conference speaker roster this year that we just have to share it with you. You’ll be receiving practical, educational information from some of the most knowledgeable experts in the field coming from some of the most reputable organizations and facilities in healthcare.

Here are our speakers and what they’ll be presenting:

Jodi L. Eisenberg MHA, CPHQ, CPMSM, CSHA, Program Manager for Accreditation and Clinical Compliance, Northwestern Hospital, Chicago

  • Regulatory changes in 2012 and top RFIs—staying ahead of The Joint Commission and CMS
  • A practical approach to policy management

Jean S Clark RHIA, CSHA, Director of Accreditation, Roper St. Francis Healthcare, Charleston, SC

  • Regulatory changes in 2012 and top RFIs—staying ahead of The Joint Commission and CMS
  • To certify or not to certify? Seeking The Joint Commission disease-specific certifications

Brad Keyes, CHSP, Consultant, Keyes Life Safety Compliance

  • What accreditation professionals still need to know about Life Safety Code®

Meagen Driskill RN, BSN, MBA, Manager of Hospital Accreditation, American Heart Association

  • Understanding hospital recognition programs for optimal cardiovascular and stroke care

Sharon Chaput RN, C, CSHA, Senior Director of Standards and Quality Management, Brattleboro Retreat, Brattleboro, VT

  • Suicide risk: Solutions to rapid assessment, Environment of Care, and documentation issues

Kirk Woodring LICSW, CGP, Director of Access, Evaluation, and Ambulatory Services, Brattleboro Retreat, Brattleboro, VT

  • Suicide risk: Solutions to rapid assessment, Environment of Care, and documentation issues

Dana Moore RN, MS, CSHA, Director of Regulatory Affairs, John Hopkins Bayview Medical Center, Baltimore

  • Understanding best practices for tracer methodology and the survey process

Greg Finch MSW, LMSW, System Director, Patient Experience and Accreditation, Arnot Health, Elmira, NY

  • Making the switch from The Joint Commission to DNV: One hospital’s experience with both surveys

Yisrael M. Safeek, MD MBA, CPE, FACPE, President of The SafeCare Group, Lexington, KY

  • Preparing for The Joint Commission OPPE & FPPE systems tracer

 Suzanne Richards, RN, MPH, MBA, Chief Clinical Officer, Prime Healthcare Management, Ontario, CA

  • The drip factor: Turning data into actionable information

Click here to view our conference webpage and learn more about this year’s conference offerings.

HHS seeks to reduce preterm births with $40m grant incentive

Last week the Department of Health and Human Services (HHS) launched a $40 million effort to reduce preterm births and ensure more babies are born healthy. Through a program called the Strong Start initiative, the Centers for Medicare and Medicaid Services (CMS) will seek to reduce preterm births by awarding grants to hospitals, healthcare providers, and community coalitions to improve prenatal care, test new methods to reverse the trend, and reduce early elective deliveries.

According to HHS, about 10 percent of all deliveries are scheduled—either as induced or Cesarean-section— before 39 weeks and are not medically indicated.

Testing for early induction of labor is addressed in the Joint Commission’s latest National Patient Safety Goal aimed at minimizing overuse of tests, treatments, and procedures in hopes to prevent harm and reduce waste. The idea is that if evidence shows no benefit, you are exposing a patient to only potential harm by giving an unnecessary test or treatment.

In fact, evidence shows the opposite. The American College of Obstetricians and Gynecologists says preterm babies (those born before 39 weeks) are at an increased risk of significant complications such as low birth weight, lung disorders, feeding problems, and blood infections, as well as long-term health problems, and an article released by Kaiser Health News said Medicaid spends $20,000 a year on babies born premature in their first year, almost 10 times that of infants born at full term.

A report by HealthLeader’s Media says reducing early elective births could save $1 billion annually, and according to a survey by The Leapfrog Group, of the 757 hospitals that volunteer to report data on obstetric care quality, too many have obstetricians who still schedule potentially harmful elective Cesareans and inductions too early rather than supporting unprompted deliveries.

To learn more about the effort to reduce preterm births, visit the CMS Innovation website.

Guess who’s coming to the AHAP conference?

Exciting news! A representative from The Joint Commission will be joining the unique roundtable discussion at the 6th Annual AHAP Conference on May 10-11 in Lake Buena Vista (Orlando), FL.

That’s right! Ann Scott Blouin, RN, PhD, FACHE, executive vice president, accreditation and certification operations for The Joint Commission will be joining us, along with Healthcare Facilities Accreditation Program (HFAP), Det Norske Veritas (DNV), and the American Heart Association on day one to answer your questions and discuss accreditation and certification options.

The 6th Annual AHAP Conference is the only event that brings survey and accreditation professionals together in an interactive, networking forum to discuss solutions and best practices to achieve continual survey readiness and compliance with ever-changing standards and regulations.

Also don’t forget, the first 50 paid registrants receive a free full-day pass to any Walt Disney World® theme park. Click here to learn more.

We’ve got a lot of great offerings this year, and you don’t have to be an AHAP member to attend! You can view the complete agenda here.

Book Excerpt: Tracking required staffing effectiveness standards

The requirements of standard LD.04.04.05 EPs 1, 7, and 13 mandate that governance receives an annual report encompassing not only system and process failures, but also sentinel event information, degree of family involvement, and actions taken to improve safety as well as the adequacy of staffing. Although the former indicators are available to track, such as patient/family complaints and a number of falls, it is not necessary to track them specifically. However, incorporating staffing effectiveness information and analysis data already being collected in the organization makes a lot more sense than the previous requirements. For example, when you are assessing patient flow issues or evaluating a patient fall, you can determine whether staffing issues such as volume, workload, complement of staff members on duty, and  competencies play a role in the analysis.

In conjunction, staffing effectiveness EPs were added to PI.02.02.01. EPs 12 through 14 address patient safety leadership notification of issues related to the analysis of undesirable patterns or trends as well as the inclusion of this information in an annual report.

Tip for success: After the overwhelming experience of complying with this standard in the past, the advice to you is to keep it simple by considering your organization’s needs. You can compile one report incorporating all the features required in the EPs to involve leadership as well as your governing board. The adequacy of staffing notation can be a simple checkbox or column added to your postevent or trends assessments and your root cause analyses as you consider staffing levels and competencies affecting the identified failure. The column or checkbox cam simply state whether staffing effectiveness was an issue. Or you could take the EPs and build these questions into your root cause analysis worksheet and other postevent or trends assessments.  They key is to aggregate this data to determine whether or not any patterns or trends are developing.

Don’t forget to educate your leadership about the importance of understanding the renewed focus on staffing effectiveness as it relates to analysis of data and opportunities for improvement. There could easily be related questions asked by surveyors during the Leadership Interview at the time of an on-site survey.

Editor’s note: This post is an excerpt from The Joint Commission Survey Coordinator’s Handbook, 13th Edition by Jean S. Clark, RHIA, CSHA, and Jodi L. Eisenberg, MHA, CPHQ, CPMSM, CSHA.

AHAP Conference poster presenters wanted!

Submit your application for the AHAP poster session now.

The 6th Annual AHAP Conference, to be held May 10–11, 2012, at the Hilton at The Walt Disney World Resort® in Orlando, FL, will include a poster session as part of its conference offerings. It’s an informal way for hospitals to share their accreditation- and survey-related successes with each other, network, and exchange ideas and information.

If you would like to present your poster at this year’s conference, please download our poster application form, complete it, and e-mail it to AHAP Associate Director Jaclyn Beck at Accepted poster presenters will receive a 50% discount off the price of conference admission.

Any and all ideas are welcome. Some poster topics to consider include the following:

  • An overview of your Accreditation program–staffing, processes, etc.
  • A successful new accreditation- or survey-related initiative you launched
  • Methods of inter-departmental collaboration
  • Successful training/educational methods
  • Performance improvement data mining and reporting techniques

Thanks, and I look forward to receiving your application.

Jaclyn Beck