RSSAuthor Archive for Matt Phillion

Matt Phillion is the director of the Association for Healthcare Accreditation Professionals and a Senior Managing Editor at HCPro, Inc., where he is the editor of the monthly publication Briefings on The Joint Commission.

CIHQ receives deemed status for acute care hospitals

The Center for Improvement in Healthcare Quality has announced that it is the latest organization to receive deemed status for acute care hospitals from CMS. This allows CIHQ’s hospital accreditation program to deem hospitals to be in compliance with CMS Conditions of Participation.

For more information on this announcement, visit CIHQ’s accreditation home page here.


Emergency Management standards revised

The Joint Commission has announced revisions to its Emergency Management standards intended to take into account leadership accountability for hospitals and critical access hospitals.

Based upon a field review conducted in 2012, these changes will go into effect as of January 1, 2014 and target leadership involvement and oversight as well as staff input.

For more on the revised standards, which will appear in the e-dition of the standards for both programs in November, visit The Joint Commission’s website.

Joint Commission announces alarm safety NPSG

The Joint Commission has announced the creation of a National Patient Safety Goal (NPSG.06.01.01) addressing growing concerns surrounding alarm safety.

The multi-phase implementation process for this new goal will begin January 1, 2014 with a second phase beginning Junuary 1, 2016.  

For specifics on the goal, including requirements and implementation expectations, visit The Joint Commission website. Our sister newsletter, Briefings on The Joint Commission, will have ongoing coverage of this new NPSG leading up to the implementation deadline as well.

AHAP Networking Call, June 19th

Hello, AHAP members. I wanted to let you know that we have set up a time for our next AHAP networking call and we’d love to invite everyone to attend. The call will take place June 19th at 3 PM EST (2 PM Central, 12 PM PST).

We have a great topic to discuss this quarter. Recently, Briefings on The Joint Commission interviewed Rachel Zastrow, MSN, RN, CCRN, and Six Sigma Black Belt about the work her organization has been doing to prevent drift. Her story is really intriguing and we’re very much looking forward to having her share it with you, as well as hearing about what your own organizations are working on in this area.

The dial-in information for all participants is below—feel free, as always, to invite any of your colleagues to listen in as well! I’d like to ask a favor of you—if you plan to attend, please email me at to let me know. This is simply so I can get a rough estimated headcount to ensure we are properly staffed as members dial in to the call. Anyone who emails ahead of time to confirm will receive an electronic copy of the BOJ article on drift in response.

Here is the dial-in information:

Participant Dial-In (Toll Free): 877-869-3841

Password: 370331

Looking forward to having you join us on the call!

A view from the podium

Our afternoon session at the 7th annual AHAP conference included a series of round table discussions, giving attendees a chance to speak in a smaller group with all of this year’s conference. Here’s a view from above:

AHAP kicks off annual conference

Today’s first few sessions have been a huge success. Our 7th annual conference kicked off with a great keynote address by Kurt A. Patton, MS, RPh, on “Joint Commission and CMS standards requirements: Keeping up with the pace of change,” pictured below, and we are currently listening to AHAP advisor Jean Clark, RHIA, CSHA present on “Solving compliance issues: Regulatory changes in 2013 and top RFIs.”

Later on today we’ll be hearing from Brad Keyes, CHSP, on “The Environment of Care documentation that the accreditation professionals never get to see,” followed by a round table discussion with all of our conference speakers and a tracers-related presentation by Jean as well. 

Joint Commission launches adult depression campaign

The Joint Commission has released the latest of its ongoing “Speak Up ™” campaign, this time intended to provide advice on identifying the warning signs of depression and getting the most out of care and treatment for depression.

The campaign was developed with the collaboration of nearly a dozen nationally recognized mental health organizations.

The Speak Up brochure, as well as supporting materials, can be found on The Joint Commission’s web site here or by clicking the link below:

CMS proposes changes to survey process

CMS has proposed to revise the survey, certification, and enforcement procedures related to CMS oversight of national accreditation organizations (The Joint Commission, DNV Healthcare, and the Healthcare Facilities Accreditation Program or HFAP). These revisions would implement certain provisions under the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA).

The proposed revisions would also, according to the CMS announcement, clarify and strengthen our oversight of accreditation organizations that apply for, and are granted, recognition and approval of an accreditation program in accordance with the Social Security Act.

The comment period for the proposed rule, which was originally intended to end on June 4, 2013, is extended to July 5, 2013.

The proposed rule can be found in the Federal Register here, or by clicking the link below:

BOJ article: CMS on accreditors

In a recent article by AHAP advisor Elizabeth Geffers, she takes a look at what the regulatory agency has to say about the various accrediting organizations and the work they did last year. Elizabeth also created a number of charts comparing the agencies based on available CMS data. We wanted to make all of those charts available to both BOJ subscribers and AHAP members.

By clicking on the link below, you can download a zipped folder containing all of the charts appearing in the story, as well as a few bonus tools as well. EDIT: Due to request, we have also added the charts in both a single-file Word format and PDF (thank you, Elizabeth, for sharing the alternative version). All three are below to download.

Zip: charts

Word document: 05-24-2013 16_0613_st03_fig01-5

PDF: 05-24-2013 16_0613_st03_fig01-5

Open positions – Phoenix, AZ

Hello, AHAP members. As a service to our membership we occasionally post job listings that are brought to our attention by members and their peers. The position below recently was sent our way and we were asked to help spread the word. Contact information is below for any follow up questions.

Position Description:

This position works under the direction of the director of accreditation. Primary responsibility is to coordinate and conduct accreditation activities for standards related to UM, DM, and CM. You will assist the director of accreditation with establishing cross-functional accreditation teams. Actively participates in meetings and leads work groups as needed. You will prepare application documents and evidence for accreditation surveys. Responds to questions on the administrative steps associated with accreditation. Performs mock accreditation audits and helps to close identified gaps.


Assist all UMV staff and UnitedHealth Group staff with quality improvement projects using NCQA/URAC standards. Integrates and incorporates current NCQA/URAC standards and methodologies in all work products. During Transition- in Phase the of T3 contract for the West Region, will assist with other start up CQM operations. This position contributes to the development of the Annual Clinical Quality Management Plan and Annual Clinical Quality Management Report.


Primary Responsibilities:

• Collaborates and facilitates with other departments to identify, develop, and evaluate projects which improve the delivery of clinical quality health care using NCQA methodology.

• Previous managerial or supervisory experience required to manage the performance of Accreditation Coordinators as identified by the Accreditation Director

• Ensures NCQA accreditation standards are incorporated and maintained in UMV

• Assists with managing multiple Clinical Quality Management projects through use of project management tools and scientific methodologies.

• Conducts training with Clinical programs re: NCQA standards

• Develops file audit tool and training and completes mock file reviews

• Identifies risk opportunities and works with Clinical programs to mitigate risks for accreditation success

• Creates project planning documents, including process flow charts, work plans using various software programs.

• Performs research, both primary and secondary, under guidance of director of accreditation.

• Effectively and sensitively communicates with others while modeling effective facilitation and management skills.

• Maintains confidentiality and non-discoverability of all activities.

• Assist in revisions of Quality Improvement projects.

• Opportunity to participate in obtaining data for clinical quality studies, including obtaining baseline data, benchmarks, interventions, monitoring, re-measurement, and reporting.

• Opportunity to assist with UMV Patient Safety quality improvement projects.

• Opportunity to provide status of all quality improvement projects at quality committees as needed.

• Performs all other duties as assigned.

Knowledge, Skills and Abilities:

• Understanding of various quality tools and models.

• Excellent written, verbal and presentation skills necessary to effectively convey goals and initiatives to team members and staff.

• Ability to manage and prioritize multiple tasks and projects efficiently and effectively.

• Ability to effectively communicate during meetings.

• Ability to maintain complete and accurate records and information.

• Ability to independently problem-solve.

• Ability to represent the Clinical Quality Management department in a positive and dynamic manner.

• Ability to work in a fast-paced, dynamic environment.

• Ability to generate quality data in an appropriate reporting format.


• High school/GED required

• Must be actively and professionally licensed as an RN or LPN in AZ

• Demonstrated ability to lead an Accreditation and Re-Accreditation survey is required

• Two + years of managerial or supervisory experience required

• Microsoft Excel, Power Point, Word proficiency

• United States Citizenship

• Ability to obtain favorable adjudication following submission of Department of Defense form SF86 NAC form SF86.


• Bachelor’s degree is preferred

• Data analysis experience is a plus

• CPHQ Certification preferred

As a requirement of UnitedHealth Group’s contract with the Department of Defense, this position requires U.S. citizenship and proof of favorable adjudication following submission of Department of Defense form SF86, (the National Agency Check or “NAC”). Successful completion of the NAC process is a requirement for continued employment in this role. NAC processing will be initiated by our TRICARE Security Officer post-offer, and can take 3-6 months for a final decision communication from the Department of Defense. Candidates will be allowed to begin employment with UnitedHealth Group in this role based on an interim clearance, and final results will be communicated as they are received. Failure to obtain final NAC approval will result in termination from this role.

To APPLY, please click on the following link AND search for job #516848. You can apply through the site and a recruiter will review your resume promptly!