Staff Training and Survey Readiness

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Staff Training and Survey Readiness: Preparing Your Organization for Accreditation and CMS Compliance

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Staff Training and Survey Readiness: Preparing Your Organization for Accreditation and CMS Compliance

Jean S. Clark, RHIA, CSHA

Staff Training and Survey Readiness provides practical guidance and tools to train leaders, physicians, and staff about accreditation and regulatory compliance requirements in easy- to- read terminology. It also provides direction on how to become excellent tracer team members and build the confidence to take ownership of an ongoing compliance program. Most importantly, with the training in this book, staff will gain a renewed focus on providing quality patient care and safety, not just for accrediting or regulatory reasons, but because of a culture shift that values patients above all else.

This book will help you:

  • Understand accreditation’s role in improving healthcare quality and safety
  • Prepare for working with The Joint Commission, CMS, and other regulatory agencies and accreditors before, during, and after the survey
  • Develop skills and tools for working with peers, leadership, and department heads to create a culture of continual readiness
  • Work with tracer tools to track improvements and encourage continuous survey readiness and a culture of safety and quality


View the Table of Contents:

Chapter 1: Accrediting/Certification Agencies: Know Your Options

Chapter 2: Training Equals Ongoing Readiness

Chapter 3: Tracers and Other Activities

Chapter 4: Let’s Get Organized

Chapter 5: Leaders and the Board: “Just Tell Me the Good and the Bad, but Keep It Short!”

Chapter 6: Medical Staff: How Does This Affect Me?

Chapter 7: The “Boots on the Ground” Staff

Chapter 8: Everyone Has to Be an Owner, Not a Renter and Every Team Needs a Coach

Chapter 9: Best Practices: Proven Success Stories

Chapter 9 Addendum: A Joint Commission Toolkit and Tracer Training PowerPoint


About the Author:

Jean S. Clark, RHIA, CSHA, has over 30 years of experience as an accreditation and health information management (HIM) director. She has served on The Joint Commission's Professional and Technical Advisory Committee and its Hospital Advisory Committee. A past president of the American Health Information Management Association (AHIMA), she received AHIMA’s Distinguished Member, Literary, and Volunteer awards. She is a well-known author and speaker on topics related to accreditation and HIM.

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Published: July 2013