Seminars

Thursday, May 10, 2012

7:00 a.m. – 8:00 a.m. Registration and breakfast in exhibit hall

8:00 a.m. – 9:15 a.m. General session—Preparing for The Joint Commission OPPE & FPPE systems tracer
Dr. Yisrael M. Safeek, MD, MBA, CPE, FACPE

9:30 a.m. – 9:45 a.m. AHAP welcome and presentation of the Accreditation Professional of the Year award

9:45 a.m. – 11:15 a.m. General session—Regulatory changes in 2012 and top RFIs—staying ahead of The Joint Commission and CMS
Jodi L. Eisenberg MHA, CPHQ, CPMSM, CSHA; Jean S. Clark RHIA, CSHA

11:30 a.m. – 12:30 p.m. General session—What accreditation professionals still need to know about Life Safety Code®
Brad Keyes, CHSP

12:30 p.m. – 2:00 p.m. Lunch in the exhibit hall

2:00 p.m. – 3:45 p.m. Roundtable

3:45 p.m. – 4:30 p.m. Break

4:30 p.m. – 5:30 p.m. Breakout Sessions (choose one of two)

1. To certify or not to certify? Seeking The Joint Commission disease-specific certifications
   Jean S. Clark RHIA, CSHA
2. Making the switch from The Joint Commission to DNV: One hospital's experience with both surveys
   Gregory Finch

5:30 p.m. Adjourn

Friday, May 11, 2012

7:00 a.m. – 8:00 a.m. Breakfast in exhibit hall

8:00 a.m. – 9:30 a.m. General session—The drip factor: Turning data into actionable information
Suzanne Richards, RN, MPH, MBA

9:30 a.m. – 9:45 a.m. Break

9:45a.m. – 10:45 a.m. General session—Understanding tracer methodology and the survey process
Dana Moore, RN, MS, CSHA

10:45a.m. – 11:00 a.m. Break

11:00 a.m. – 12:30 a.m. General session—A practical approach to policy management
Jodi L. Eisenberg MHA, CPHQ, CPMSM, CSHA

12:30 p.m. – 2:00 p.m. Lunch on your own

2:00 a.m. – 3:00 p.m. Breakout sessions (choose one of two)

1. Suicide risk: Solutions to rapid assessment, Environment of Care, and documentation issues
   Sharon Chaput, RN, CSHA; Kirk Woodring, LICSW, CGP
2. Understanding hospital recognition programs for optimal cardiovascular and stroke care Meagen Driskill, RN, BSN, MBA

3:00 p.m. Adjourn

*Agenda topics are subject to change.

Learning Objectives:

• Identify information that accreditation professionals should regularly receive about Life Safety ®issues
• Decrease facility exposure to frequent and common findings
• Manage proper documentation for Life Safety Code® compliance
• Prepare a facility for an extra day of survey
• Discuss the similarities and differences of TJC and DNV standards and surveys
• Understand how the integration of CMS COPs with ISO 9001lead to the NIAHO standards
• Apply ISO quality improvement principles that are utilized in DNV standards
• Formulate a strategy to evaluate which accrediting body best fits an organization's culture
• Identify ways to assess organizational readiness and correct vulnerabilities
• Apply tracer strategies to improve compliance in frequently cited "high-risk" areas
• Demonstrate second-generation tracers to prioritize improvements in systems and processes
• Discuss The Joint Commission's disease-specific certifications and decision-making factors regarding applying
• Understand the application process and the data submission process for Joint Commission disease-specific certifications
•  Organize and motivate a certification team  for continual compliance
• Describe one hospital's experience with a certification survey and identify best practices for survey readiness
• Demonstrate an understanding of the Sentinel Event alert released in November 2010 and its impact on non-behavioral health settings
• Understand the TJC and CMS standards related to screening patients and assessing the environment of care (EC) for suicide risk
• Identify and implement risk reduction solutions and strategies
• Demonstrate best practices and tools for documenting for suicidal risk

Who should attend?

• Accreditation professionals
• Survey coordinators
• Quality managers
• Risk managers
• Performance improvement directors
• Nurse managers
• Patient safety officers
• CNOs
• CCOs
• CEOs
• Directors of accreditation

Jodi L. Eisenberg MHA, CPHQ, CPMSM, CSHA
Program Manager for Accreditation and Clinical Compliance

Ms. Eisenberg is the manager of clinical accreditation & policy management at Northwestern Memorial Hospital in Chicago. She is also the chair of the AHAP advisory board and has more than 20 years of experience in healthcare administration. In her current role, she leads a full range of Joint Commission and other accreditation and regulatory compliance activities to promote a state of constant survey readiness.

Jean S Clark RHIA, CSHA
Director of Accreditation

Ms. Clark is the director of accreditation at Roper Saint Francis Healthcare in Charleston, SC. She has served on The Joint Commission (JCAHO) Standards Review Task Force and the expert panel for the Information Management chapter, which resulted in sweeping changes for the accreditation process beginning in January 2004. A past president of the American Health Information Management Association (AHIMA), she received AHIMA's Distinguished Member Award and the Volunteer Award. She is the past president of the International Federation of Health Record Organizations (IFHRO).

Brad Keyes CHSP
Consultant

Mr. Keyes is the owner of KEYES Life Safety Compliance and his expertise is in the management of the Life Safety Program, including the Environment of Care and Emergency Management programs. Keyes analyzes and develops leadership effectiveness and efficiency in work processes, focusing on assessing an organization's preparedness for survey, evaluating processes in achieving preparedness, and guiding organizations toward compliance.

Meagen Driskill RN, BSN, MBA
Manager of Hospital Accreditation

Ms. Driskill is the manager of hospital accreditation for the American Heart Association. She is responsible for the leadership of the hospital accreditation business model and leads the organization's collaboration on hospital accreditation programs with the Society of Chest Pain Centers and The Joint Commission. With more than twenty years of healthcare experience, Driskill has work experience in critical care, emergency management, performance improvement, quality management, and service line development for several healthcare systems.

Sharon Chaput RN, C, CSHA
Senior Director of Standards and Quality Management

Ms. Chaput is the director of standards and quality management at the Brattleboro Retreat in VT. Chaput has 24 years of experience as an RN with 20 years working in behavioral health in various positions, including charge nurse, nurse manager, and program director. Chaput is considered to be a national field expert in healthcare accreditation. She assisted in developing the national Certified Specialist in Healthcare Accreditation (CSHA) exam, has spoken at national accreditation professionals conferences on suicide risk assessment, and has provided consultative services for hospitals on Joint Commission survey readiness

Kirk Woodring LICSW, CGP

Mr. Woodring is a licensed independent clinical social worker and the director of access, evaluation, and ambulatory services at the Brattleboro Retreat. Woodring has presented nationally on the assessment of suicide risk and has worked and consulted with emergency department doctors, nurses, and social workers in hospitals throughout New England on developing skills for rapidly assessing risk.

Dana Moore RN, MS, CSHA
Director of Regulatory Affairs

Ms. Moore is the director of regulatory affairs at John Hopkins Bayview Medical Center. She has been in the regulatory arena for over five years, and her responsibilities include assuring the organization is a continuous readiness state and ensuring the organization maintains its eight different Joint Commission accreditations and certifications. Her previous experience and education includes trauma, critical care, clinical nursing, and patient safety.

Greg Finch MSW, LMSW
System Director, Patient Experience and Accreditation

Mr. Finch is the system director, patient experience and accreditation, at Arnot Health in Elimira, NY. Finch served as the Director of Medical Social Work at Arnot Ogden Medical Center from 1988 to 2006 when he assumed responsibility for Patient Satisfaction & Accreditation. Finch also managed the hospitals Bariatric Surgery Program that performed over 2,000 weight loss surgeries from 2004-2010. Since assuming leadership for accreditation Greg has successfully transitioned the Arnot Ogden Medical Center from a Joint Commission Accredited hospital to receiving Det Norske Veritas accreditation. Currently he is leading activities to gain DNV accreditation for the remaining two hospitals in the Arnot Health system.

Yisrael M. Safeek, MD MBA, CPE, FACPE

Dr. Safeek is the President of The SafeCare Group, an organization helping to lead the transformation of health care. He worked with The Joint Commission in 2009 to produce the Systems Tracer "Evaluating Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE) Processes." This effort culminated with the OPPE and FPPE Booster Pak that is being utilized in over 18,000 accredited organizations. He is the first Kentucky physician to be appointed to the Board of Examiners for the Malcolm Baldrige National Quality Award program. He previously served as the Chief Quality Officer for 18-hospital Covenant Health System and in 2007 led a primary teaching hospital to National Hospital of the Year and the state Excellence Award. He has published works in such prestigious healthcare journals like Physician Executive and Healthcare Financial Management. He is the author of the book, Credentialing & Privileging for Accountable Care.

Faculty Disclosure Statement

HCPro, Inc., has confirmed that none of the faculty/presenters, planners, or contributors have any relevant financial relationships to disclose related to the content of this educational activity.

Speakers subject to change.

Nursing Contact Hours (ANCC)
HCPro, Inc., is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.

This educational activity for 11 nursing contact hours is provided by HCPro, Inc.

National Association for Healthcare Quality (NAHQ)
This activity will be submitted to the National Association for Healthcare Quality for CPHQ CE credits.

Certified Specialist in Healthcare Accreditation (CSHA)
This program has been approved for 11 continuing education units towards fulfilling the requirements of the Certified Specialist in Healthcare Accreditation certification, offered as a service of the Association of Healthcare Accreditation Professionals (AHAP).

Hilton in the Walt Disney World Resort
1751 Hotel Plaza Boulevard | Lake Buena Vista, FL 32830
407/827-4000
Online Hotel Reservations

Discounted Room Rate (deadline: April 6, 2012): $139 per night

The Hilton in Walt Disney World® Resort is located directly across from Downtown Disney® in Lake Buena Vista, and only steps away from popular Disney attractions including: Magic Kingdom®, Animal Kingdom® Theme Park, Hollywood Studios™, Epcot®, Typhoon Lagoon® Water Park, and Blizzard Beach® Water Park. It is also located close to a number of Orlando's best attractions, beaches and shopping—SeaWorld, Universal Studios and Islands of Adventure, Kennedy Space Center, Daytona Beach, Clearwater Beach, Mall at Millenia, and Orlando Premium Outlets. Guests of the Hilton will find seven restaurants and lounges, a 24-hour Gourmet Marketplace, two outdoor heated swimming pools, a kid's spray poot, and tropical outdoor spa.

Regular Rate	$995.00 individual attendee	$3,980.00 team of five
Member Rate	$795.00 individual attendee

1. Cancellations received by HCPro, Inc. 30 days or more prior to the seminar are eligible for a credit or refund, less a $250 cancellation fee. The credit will be valid for up to 6 months from date of cancellation.
2. Cancellations made 30 to 10 days prior to the seminar date(s) are not eligible for refunds but are eligible for payment transfer (credit) to another HCPro, Inc. seminar, less a $250 cancellation fee. The credit will be valid for up to 6 months from date of cancellation.
3. Participant(s) who cancel less than 10 days prior to the seminar date(s) will be considered as "no shows" and will not be eligible for refunds/credits.

This policy is subject to change.

Reserve your space today!
Call Paul Mattioli at 781/535-4926
or download the prospectus and application attached and e-mail to pmattioli@hcpro.com.
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