Q&A: Accreditation 101

Briefings on Accreditation and Quality, September 1, 2017

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Two experts explain what new accreditation specialists need to know

Editor’s note: The accreditation world can be a perplexing place. Accreditation specialists are expected to be up to date on forever-shifting healthcare regulations. They have to make sure every aspect of their facility is compliant with federal, state, and private standards and guidance. And when something is wrong, they have to ensure it gets and stays fixed.

This article is a primer for accreditation beginners: people who want to do their jobs well but need an idea of where to start.

The following answers come from Nan Tomsky, MN, RN, CPHRM, a principal consultant at Compass Clinical Consulting, and Richard Curtis, RN, MS, HACP, CEO of the Center for Improvement in Healthcare Quality and a nationally recognized expert on the CMS Conditions of Participation (CoP) and certification and survey process.

Q: What qualifications does someone need to be an accreditation specialist? What sort of background?

Tomsky: Ideally, qualifications would include a bachelor’s degree and three to five years of clinical experience in the hospital setting. Ideally, a bachelor’s degree in a healthcare-related field would be recommended. It is not absolute, however. For instance, a degree in business combined with healthcare experience would be a plus.

Experience in a department/specialty that interacts with patients and/or a wide variety of clinical or organizational departments is also a real plus. As a result, registered nurses are often preferred, but other disciplines are equally well qualified. I have had the pleasure of working with accreditation specialists whose backgrounds included social work, case management, laboratory, education, and even healthcare law.

The most important quality in a candidate is real commitment to and interest in helping the organization understand and implement practices to support accreditation and improve patient care, safety, and outcomes.

Curtis: Personally, I am less concerned with how many letters someone has after their name than I am about their experience working in the field of regulatory compliance and their knowledge of accreditation standards and the CMS CoPs.

As importantly, the right person has an inquisitive mind, excellent communication skills, pays attention to detail, can work with all levels of an organization (from the chair of the board to the housekeeper), and above all else has a passion for the job and doing the right thing.

Q: What does an average day as an accreditation specialist look like? What tasks are they expected to do?

Curtis: I’d say right off the bat that no two days are alike. A lot of time is spent researching regulations and advising others on what they can and can’t do from a regulatory standpoint.

In many ways, I liken an accreditation specialist to internal affairs at a police department. The job is to make sure that policies are followed and standards are met. You won’t be the most popular person around, but the work you do is vital. Imagine if no one was “watching the store.”

Tomsky: One of the reasons this position is an interesting and challenging one is that there is rarely an average day. Routine parts of a day can include scheduled meetings, reviewing policies and procedures, data review, and researching best practice. At least weekly, joining others in patient safety rounds, Environment of Care (EOC) rounds, or other mock survey activities can be anticipated.

 An accreditation specialist will be expected to keep up to date on changes to standards (or their interpretation), both for the accrediting body for their organization and CMS’ CoPs as well as developing a working knowledge of state statutes as they relate to policies and procedures.

Active participation in leadership meetings, quality committee meetings, EOC committee meetings, patient safety committee meetings, grievance and complaint committees, and route cause analysis team meetings would be expected. Education is also a key component for the accreditation specialist position. Education efforts include formal presentations at meetings and just-in-time training, as well as passive education efforts, such as development of screen saver messages or posters.

Chairing an accreditation committee is often an expectation. The specialist is also responsible for establishing a survey response plan to include, among other things, notification to leaders and others that the survey team has arrived, document availability, identification of scribes, and communication during survey to stakeholders.  

This is an excerpt from a member only article. To read the article in its entirety, please login or subscribe to Briefings on Accreditation and Quality.

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