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Joint Commission highlights need for disaster planning following Boston bombings

In a recent post to their site, The Joint Commission announces that the organization is ready to assist member hospitals with increased demands for disaster preparedness following the Boston Marathon bombings.

The Joint Commission requires development of a disaster plan by all accredited organizations via the Emergency Management chapter, and provides guidance for “all hazard” events as well as methods to maintain vigilance in preparation for such events.

For more information on the services The Joint Commission provides for disaster planning, visit here.

Joint Commission awards ambulatory accreditation to kidney care center

For the first time, The Joint Commission has awarded accreditation through its Ambulatory Health Care program to an inpatient kidney care provider. Denver-based DaVita Hospital Services became the first organization to receive this type of accreditation.

DaVita has a presence in over 700 Joint Commission accredited hospitals across the country. According to The Joint Commission, this designation is meant as a supplement to other forms of accreditation and is intended to help improve care and reduce risk through continual readiness.

“Accreditation from The Joint Commission is the foundation to improve the standardization of clinical and operational processes,” said Robert Provenzano, MD, vice president of medical affairs, DaVita, in an official press release. “Through this, DaVita is able to assist our hospital partners in risk management, survey preparedness and enhancements to the quality and safety of patient care.”

More on The Joint Commission’s ambulatory care program can be found here.

Job listing

Hello, AHAP member. I just wanted to share with you a job listing that was sent our way via one of our member contacts–as you know, we happily share job openings upon request to help accreditation specialists connect professionally. Please contact the link below with any followup questions.

UnitedHealth GroupTRICARE Accreditation Manager – Phoenix, AZ – (Job #516848)

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.

UnitedHealthcare Military & Veterans is part of the family of companies that make UnitedHealth Group one of the leaders across the US health care system.

We serve those who serve our nation, providing quality health care services to millions of military beneficiaries across the (list region post award).

Our commitment to helping people live healthier lives, and to continue the honor, satisfaction, and quality of the TRICARE military health benefit program is greater than ever. Our efforts complement the Military Health System to demonstrate the best blend of public and private health care solutions.

It’s not just business as usual. It is one of our proudest endeavors.

If you’re ready to help make health care work better for those who serve our nation. If you are smart, creative, and committed. If you want to make a difference. Consider being part of the elite team at UnitedHealthcare Military & Veterans.

This is an opportunity to share in something special; a chance for all of us to serve, to excel, and to know that we’ve made a difference for those families who have made our nation stronger.

Diversity creates a healthier atmosphere: equal opportunity employer M/F/D/V

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, or national origin.

UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment. In addition, employees in certain positions are subject to random drug testing.

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!

2014 NPSG proposed on alarm management

This has been making the rounds, but had not yet been posted to the blog yet–for your convenience, we thought it would be helpful to add the link.

The Joint Commission has put forth a proposed National Patient Safety Goal for 2014 addressing alarm management in hospitals and critical access hospitals. According to the official announcement, these proposed changes will address compromised safety as a result of staff overwhelmed and desensitized due to ever-present and over-present alarms in the healthcare setting.

Further details can be found here or by copying and pasting the link below into your browser.

Columbus Regional Hospital recognized as first Heart Failure Center in its class for 2013

Columbus Regional Hospital has been recognized by the Healthcare Accreditation Coloquium as the first community-based independent hospital to achieve Heart Failure Center re-accreditation in 2013.

The colloquium has pioneered “continual accreditation” requiring hospitals to add additiaonl heart failure services to their communities each year.

For more on the official announcement and on the colloquium itself, visit

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

UK medical chief calls antibiotic resistance “catastrophic threat”

We’ve often heard that the building up of resistances to antibiotics by bacterial infections is a growing (and creeping) risk, but England’s top medical official had quite a bit to say on it in a recent statement. Check out the following, from Reuters:

Antibiotic resistance poses a catastrophic threat to medicine and could mean patients having minor surgery risk dying from infections that can no longer be treated, Britain’s top health official said on Monday.

Sally Davies, the chief medical officer for England, said global action is needed to fight antibiotic, or antimicrobial, resistance and fill a drug “discovery void” by researching and developing new medicines to treat emerging, mutating infections.

 The full article can be found online here.


Joint Commission releases new “Speak Up” offering

The Joint Commission has released the latest in its ongoing series of “Speak Up” patient education and self-advocacy videos this week. This latest video addresses pain and how a patient, as well as their families, can take an active role in their own pain management and assessment.

 The video discusses not only the types of pain and how to identify them, but methods for communicating that pain to your caregiver, reasons why it is often better to identify and treat pain rather than trying to “tough it out,” pain’s impact on the speed of healing, and alternative means to address the pain itself.

The video can be viewed here.

Portland hospital investigated after child’s clothing unexpectedly catches fire

Here is a story that will cause more than one hospital to take a look at its own policies and procedures:

Earlier this week an 11-year-old cancer survivor and patient of Doernbecher Children’s Hospital ran from her hospital room with the front of her tee-shirt on fire. The child, who will need skin grafts and burn treatment for her injuries, was at the hospital after hitting her head at school.

Now an investigation is underway to find out whether a combination of hand sanitizer and static electricity are behind this terrible event. The incident raises questions as part of an ongoing debate–manufacturers of non-alcoholic hand sanitizers cite dangers of fire as a reason for using their products, while experts, including the Center for Disease Prevention and Control (CDC) still feel that alcohol-based sanitizers are the single most effective way of preventing transmission of germs.

AHAP members: what is your reaction to this event? Has it made you look into your own policies on hand sanitizers? Or is this one of those rare cases where a series of unfortunate occurances led to a tragic event that was otherwise impossible to predict? Share your thoughts below, or on the listserv.

For more on this story, visit the Oregonian’s website.

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.