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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.

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.

EOC chart

We’ve had a few requests to repost the EOC chart discussed in a recent post in a different format, as many readers were having trouble opening it in Word. Please find at the link below a new PDF version which should open up in a much easier to download format for you.

4th and final 2012 benchmarking report posted!

Happy New Year, AHAP members! We just wanted to let you know that our last benchmarking report of 2012 has been posted to the site for you to download. It compares and contrasts the widely varied job responsibilities and job titles of AHAP members and other survey coordinators across the country.

You can find the report here, or by copying and pasting the URL below into your browser. (Note: You will need to be logged in to view the report, which is free for all members.)

We look forward to publishing more reports for you in the coming year!