2023 Accreditation Professional Orientation Certificate Program - Session 1

April 25, 2023 to April 28, 2023

This activity will provide the participants with a foundational understanding of the continuous accreditation and regulatory readiness process from a regulatory / accreditation perspective.  Participants will learn about the history of healthcare regulations / accreditation; regulatory / accreditation sources of truth; managing the continuous readiness process prior to, during and following an external survey visit.   Each session will include perspective from those who have successfully addressed requirements and/or a resource to help the participant in their compliance strategy. There will be facets of this program that address knowledge, competence and performance.

Target Audience


Other healthcare professionals

Learning Objectives

At the conclusion of this activity, participants should be able to:

  1. Identify the key functions and responsibilities that must be integrated into operations to ensure continuous accreditation compliance and the various approaches that may be used to sustain continuous accreditation compliance.
  2. State the fundamental requirements of the CMS hospital and critical access CoPs
  3. Explain how to engage operational partners and content experts within an organization to ensure continuous accreditation compliance and optimize effectiveness as accreditation professionals. 
  4. Recognize resources available through collaboration and networking with other member accreditation professionals.
  5. Demonstrate teamwork among participants.
  6. Outline the critical activities of a continuous accreditation compliance model organization undergoing an on-site accreditation survey
  7. Define the activities that various continuous accreditation compliance model organization staff perform during an on-site accreditation survey
  8. Describe the appropriate technique for challenging surveyor findings while surveyors are on-site
  9. Outline the critical activities that must occur immediately after accreditation surveyors have left the organization
  10. Identify and discuss the process for reviewing post-survey report and prioritizing findings, potential clarifications (TJC only) and corrective action plans
  11. Explain the differences between CMS post-survey report response and voluntary accreditation survey reports
  12. Recognize the required elements for submitting clarifications (TJC only) and corrective action plans
  13. Outline the foundational expectations for Life Safety Compliance
  14. Identify and examine the common vulnerabilities to a Successful Life Safety Program
  15. Discover strategies for partnering with the Facilities Management staff to ensure successful implementation of a compliant Life Safety Program
  16. Develop accreditation communication plans using tools and resources provided.
Course summary
Available credit: 
  • 14.00 ANCC
  • 14.00 CBRN
  • 14.00 General CE – Attendance
Course opens: 
Course expires: 
Event starts: 
04/25/2023 - 10:00am CDT
Event ends: 
04/28/2023 - 1:30pm CDT


Natalie Webb, MHA, RN, CPHQ
Accreditation Director
Vizient, Inc.

Robert Durkee, MHA, RN, FACHE
Sr. Director Accreditation Advisory Services
Vizient, Inc.

Diana Scott, MHA, RN, CPHQ
Principle, Accreditation Advisory Services
Vizient, Inc.

Ahnna Parker, MSN, RN-BC, CIC
Advisor, Accreditation
Vizient, Inc.

Gina Holiway, MHA, MSN, RN
Advisor, Accreditation
Vizient, Inc.

Joseph Belino, MS, LSCS, CHFM
L/S Advisor, Accreditation
Vizient, Inc.


Planning committee

Natalie Webb, MHA, RN, CPHQ
Accreditation Director
Vizient, Inc.

Robert Durkee, MHA, RN, FACHE
Sr. Director Accreditation Advisory Services
Vizient, Inc.


Absence of Relevant Financial Relationships

Vizient, Inc., Jointly Accredited for Interprofessional Continuing Education, defines companies to be ineligible as those whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

An individual is considered to have a relevant financial relationship if the educational content an individual can control is related to the business lines or products of the ineligible company.

No one in a position to control the content of this educational activity have relevant financial relationships with ineligible companies.


Statement of Content Validity

Vizient, Inc. educational activities are intended to assist healthcare teams advance their professional responsibilities in accordance with the definition of continuing education. It is the policy of Vizient, Inc. to review and ensure that all content and recommendations for patient care within accredited CE is evidenced-based, based on current science and clinical reasoning while ensuring the content is fair and balanced. All recommendations must conform to the generally accepted standards of experimental design, data collection, analysis, and interpretation. Vizient, Inc. does not permit accredited continuing education if it advocates for unscientific approaches to diagnosis or therapy, or if the education promotes recommendations, treatment, or manners of practicing healthcare that are determined to have risks or dangers that outweigh the benefits or are known to be ineffective in the treatment of patients.


FDA off-label/unapproved usage

Faculty/Presenters are required to identify any new and evolving topics for which there is a lower/absence of evidence base. This is to ensure that our content does not advocate for, or promote, practices that are not, or not yet adequately based on current science, evidence, and clinical reasoning. Faculty/Presenters are required to disclose any discussion of (1) off-label/unapproved or investigational uses of FDA approved commercial products or devices and/or (2) products or devices not yet approved in the United States.

Disclaimer: The education provided through this activity is for continuing education purposes only. The views and opinions expressed in this activity are those of the faculty/presenters and do not necessarily reflect the views of Vizient, Inc.

In support of improving patient care, Vizient, Inc. is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC) to provide continuing education for the healthcare team.


Designation Statement(s):


This activity is designated for 14.00 contact hours.

Vizient, Inc. is approved by the California Board of Registered Nursing, Provider Number CEP12580, for 14.00 contact hours.



Vizient, Inc. will award all other healthcare professionals who successfully complete the activity a Certificate of Participation indicating the maximum credits available. Various state license boards and credentialing bodies accept certificates of participation from accredited CE activities to meet CE requirements for license renewals and re-certification. It is the responsibility of the participant to contact their state licensing board and/or certifying body for verification on credit eligibility reciprocity.

Available Credit

  • 14.00 ANCC
  • 14.00 CBRN
  • 14.00 General CE – Attendance