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Accreditation Specialist Boot Camp

Course Outline

Module 1: Assessment
  • Maintaining expertise on accreditation and regulatory issues
  • Interpreting standards and regulations for organization
  • Assessing organizational readiness and vulnerabilities for external evaluation by regulatory bodie
  • Measuring organizational compliance with standards
  • Interpreting future trends likely to affect organizational compliance
Module 2: Education
  • Disseminating information on standards and regulations to organization
  • Educating organizational staff on standards and regulations (e.g., orientation, in-service)
  • Simplifying the link between the standard and the organization's practice
  • Collaborating with leadership in establishing accountability for organizational compliance with standards/regulations
  • Directing organizational staff performance to achieve compliance with standards/regulations
Module 3: Implementation
  • Building collaborative relationships within the organization
  • Establishing multi-disciplinary team
  • Applying meeting management skills
  • Facilitating multi-disciplinary team to achieve standards compliance
  • Employing change management skills to achieve compliance with standards
  • Resolving conflict by employing negotiation and mediation skills
  • Establishing position as expert resource
  • Synthesizing the roles and responsibilities of the structural components of the organization
  • Translating standards into actions
  • Integrating standards with organizational policies and procedures
  • Implementing practical applicability of standards
  • Executing evidence-based approaches to patient safety and performance improvement
  • Acting as professional to regulatory agencies
  • Implementing plan for continuous survey readiness (e.g., mock surveys, tracer methodology)
  • Ensuring documentation is in compliance with regulations/standards (e.g. PPR, eBBI, PFI)
  • Resolving non-compliance issues with plan of correction (e.g., pre and post)
  • Coordinating site visits
  • Implementing follow up to site visits (e.g., reports, clarifications)
  • Coordinating disease specific certification and other related surveys


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