Accreditation 101: A Toolkit for Accreditation Professionals

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Accreditation 101: A Toolkit for Accreditation Professionals

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Accreditation 101: A Toolkit for Accreditation Professionals

Heather Forbes, BSN, RN, CEN, HACP

Accreditation is a complex topic with multiple branches, specialties, and nuances. New accreditation specialists often come from disparate backgrounds, with huge variations in the type and amount of training (if any) they had before accepting their new role. There’s a steep learning curve involved, with countless terms, organizations, and processes to understand and no clear method to go about it.

Accreditation 101: A Toolkit for Accreditation Professionals provides a road map to the new specialist’s education and orientation, with plenty of guidance along the way. Written in clear, accessible terms, Accreditation 101 comes with downloadable tools, mock tracers, timely updates, newsletter articles, and educational chapters that will aid everyone in your department.

This online toolkit is ideal not only for someone new to the specialist role, but also as an orientation resource that leadership can provide to incoming specialists with prior experience.

This toolkit will benefit leadership by being:

  • Affordable and reusable: Specialist positions are sometimes fraught with high turnover. This resource makes sure your new hires get up to speed quickly, without breaking your budget.
  • Simple to access: All parts of this toolkit can be found in a single, easy-to-navigate online resource.
  • Comprehensive: The resources in this toolkit cover not only accreditation for CMS, but The Joint Commission, DNV, and other accrediting organizations.
  • A true beginner’s resource: All documents in the toolkit are written in clear, simple language, with no assumptions about what the reader already knows.


About the Author:

Heather Forbes, BSN, RN, CEN, HACP, is an independent healthcare accreditation consultant with a passion for mentoring new accreditation consultants and leveraging regulatory standards for improving patient safety across all continuums of care. In addition to accreditation and regulatory readiness, she has experience in leadership, critical care nursing, healthcare technology, and developing and implementing sustainable clinical education programs. Forbes is a published author, speaker, and consultant for healthcare accreditation, including The Joint Commission and CMS. She is an honors graduate of Northeastern University.


Published: July 2018
Electronic Format
ISBN: 978-1-68308-805-9

Table of Contents

  • What is accreditation?
    • Overview of the field
    • Differences between accreditation organizations
    • Why it matters
  • What does an accreditation specialist do?
    • What tasks are you expected to perform?
    • What skills and knowledge will you need?
    • By what benchmark will your success be measured?
    • How do you keep your documents in order?
  • How does the survey process work?
    • What’s the timeline of an accreditation survey?
    • How will surveyors let you know they’re coming? How long will they be there?
    • What are staff supposed to do during this time?
    • What will surveyors do if they find deficiencies?
    • What happens after surveyors leave?
    • What are the differences between CMS, TJC, DNV, and HFAP survey processes?
  • How do you prepare for a survey?
    • What things will you need to be on the lookout for?
    • How do you know when you’re ready for the surveyors to come?
    • How do you get staff ready?
  • How do you fix a problem?
    • What’s the process once you uncover a problem?
    • How do you handle survey deficiencies, RFIs, or immediate jeopardy findings?
    • What if you uncover a problem that would take a lot of time/money to fix? What’s the best way to bring it to leadership?
  • How do you sustain compliance?
    • How do you ensure that once you fix something, it stays fixed?
    • How much authority do you have to enforce compliance in a hospital?
    • What can you do if your compliance instructions are ignored?
    • What do you do if there’s a quality improvement project you want to undertake?
  • How do you work with colleagues?
    • How do you get leadership to take you and your concerns seriously?
    • How do you get staff to buy into your compliance changes and fixes?
  • Resources, tools, and education
    • What are some of the methods you can use to educate staff on compliance?
    • What are mock tracers, and what are they for?
    • Suggested reading
  • What are the current major areas of concern in accreditation?
    • List of hot topics (suicide prevention, Legionella, life safety, etc.)