How to Interpret Problematic Conditions of Participation and Accreditation Standards (Recorded Webinar)

Date: Thursday, May 5, 2016
Time: 2:00 – 3:00 pm ET (1:00 – 2:00 pm CT)

Speaker: Jonathan Burroughs, MD, MBA, FACHE, FAAPL

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Accreditation standards provide an opportunity to adopt 'best practices' that benefit optimum patient outcomes. Unfortunately, many get overly proscriptive in their interpretation of accreditation standard intent and so inadvertently create scenarios that add complexity, cost, and confusion. There are an infinite number of ways to interpret accreditation standards; however, the ideal way for each organization will reduce operating cost, reduce complexity, and support optimal patient outcomes.

This program covers the most problematic accreditation standards-past, present, and future and demonstrates how they can be looked at with fresh eyes to improve quality outcomes and reduce costs.

These standards include: medical history and physical, updated exam and chart entries, verbal orders,
date/time/authentication of written orders, informed consent, discharge process and summary, completion of medical records, single governing board and medical staff, medical staff member on governing board, podiatrists as medical staff leaders, self-administered medications, standing orders, verbal orders update, practitioners who may order outpatient services, emergency management/operations plan, and the improvement of the safety of clinical alarm systems.

Each standard will be discussed with the intent to create options for interpretation that make both clinical and operational sense and provide better care at lower cost to the patient we serve.

What You Will Learn:

At the end of these presentations, participants will be able to:

  • Understand why the interpretation of accreditation standards must be collaborative and make both clinical and operational sense
  • Learn how to interpret traditional and operational conditions of participation/accreditation standards so that they make clinical and operational sense
  • Learn how to work with the medical staff in new ways to create innovative interpretations that work for both patients and operational necessity

Speaker Bio:

Jonathan H. Burroughs, MD, MBA, FACHE, FAAPL is President and CEO of The Burroughs Healthcare Consulting Network, Inc. and works with some of the nation’s top healthcare consulting organizations to provide ‘best practice’ solutions and training to healthcare organizations throughout the country in the areas of governance, physician–hospital alignment strategies, credentialing, privileging, peer review and performance improvement/patient safety, medical staff development planning, strategic planning, physician performance and behavior management, as well as ways in which physicians and management can work together in new ways to solve quality, safety, operational, and financial challenges through the creation of population health programs and clinically integrated networks.

Dr. Burroughs serves on the national faculty of the American College of Healthcare Executives and the American Association for Physician Leadership, where he has been consistently rated as one of their top speakers and educators. In 2014, he and Dr. David Nash were awarded a development grant by the American College of Healthcare Executives (ACHE) to develop a twelve hour national program to address population health and the disruptive innovative business models necessary to support it. He will develop a two day advanced physician leadership program for AAPL which will be introduced at the Fall Institute in Arizona. He is the author or coauthor of the following  books:  Redesign the Medical Staff Model-A Collaborative Approach  (published by Health Administration Press, January, 2015 and honored with the 2016 James A. Hamilton Award for outstanding healthcare management book), The Complete Guide to FPPE (2012), Medical Staff Leadership Essentials (2011), Engage and Align the Medical Staff and Hospital Management: Expert Strategies and Field Tested Tools (2010), A Practical Guide to Managing Disruptive and Impaired Physicians (2010), The Top 40 Medical Staff Policies and Procedures, Fourth Edition (2010), Emergency Department On-Call Strategies: Solutions for Physician-Hospital Alignment (2009), and Peer Review Best Practices: Case Studies and Lessons Learned (2008).

Who Should Attend:

Medical services professionals, credentialing professionals, and credentials committee members interested in will discovering how a fully electronic solution that enables the collection of a more robust provider data set could save time during the credentialing process .


NAMSS Members: $55
Non-Members: $75
Group Purchase: $150 (Provides access to the webinar and five (5) individual CE certificates)
Additional CEs (beyond 5): $85 per 10 additional certificates. Purchase as many packs of 10 as you need.

CE Credits:

This webinar has been approved for 1.0 CE Credits.