Toolkit for New Accreditation Professionals, 2nd Edition
All levels
U.S. Standards

Toolkit for New Accreditation Professionals, 2nd Edition

Revised and refreshed, this toolkit helps new accreditation professionals get up to speed and ready for survey!

Release Date: May 2017. 226 pages.

  • An individual license is intended for single users only. This ebook cannot be shared, disseminated, downloaded, or posted for widespread or public use. 
  • site license allows this ebook to be shared among unlimited users but only within one facility or site, either by posting to a secure intranet site or by providing other means of secure access. 
  • system license allows this ebook to be shared among unlimited users within all facilities or sites within a health care system, either by posting to a secure intranet site or by providing other means of secure access. Please contact JCR Customer Service (877.223.6866 option 1) for pricing of a system license.

Product Description

Product Description

The second edition of Toolkit for New Accreditation Professionals has been fully updated to account for all the standards and survey process changes associated with The Joint Commission’s Project REFRESH and the introduction of the SAFER™  Matrix. Additionally, it was revised to reflect the adoption of the 2012 Life Safety Code®
Now available in print or as an e-toolkit, the Toolkit supports accreditation professionals new to their role. Or, veteran accreditation professionals can use it to educate and mentor staff about The Joint Commission. Applicable to all accreditation programs, it presents key concepts in clear, concise language and a colorful and easy-to-follow format. Dozens of tools are integrated into the core content.
Key Topics
  • Accreditation cycle and survey process, including the SAFER matrix
  • Working with data
  • Challenging requirements
  • Core concepts from all standards chapters, covering performance improvement, leadership, staffing, care of the patient, records and information technology, infection prevention and control, medication management, the physical environment, and testing and transplants
Key Features
  • Focused on concepts critical to patient safety and survey success
  • Practical activities for learning and applying the key concepts
  • More than 50 downloadable, customizable tools (linked in the e-toolkit or on the included flash drive for the print version)
  • Glossary terms with simple, straightforward definitions
  • Appendixes with Focused Standards Assessment risk charts; orientation, training, and education requirements; credentialing, privileging, qualifications, and competencies requirements; resources for each key concept in the chapters; and correlations of the chapter content to National Patient Safety Goals
  • Developed by Joint Commission experts and customer advisors
Settings: Ambulatory Care, Behavioral Health Care, Critical Access Hospital, Home Care, Hospital, Office-Based Surgery, Nursing Care Centers, Laboratory
Standards: All standards
Audience: New accreditation professionals

Joint Commission Resources, Inc. (JCR), a wholly controlled, not-for-profit affiliate of The Joint Commission, is the official publisher and educator of The Joint Commission.

JCR is an expert resource for health care organizations, providing advisory services, educational services and publications to assist in improving quality and safety and to help in meeting the accreditation standards of The Joint Commission. JCR provides advisory services independently from The Joint Commission and in a fully confidential manner.

Table of Contents

Table of Contents



Chapter 1: Survival Skills
The Big Idea
Key Concepts
  • Getting Oriented
  • Building Relationships
  • Finding a Mentor
  • Communication and Teamwork
  • Gaining Skills and Confidence
Chapter 2: The Accreditation Cycle and the Survey Process
The Big Idea
Key Concepts
  • The Application Process
  • Survey Readiness
  • The On-Site Survey Process
  • Deemed Status
  • After the Survey
  • Continuous Compliance
Tools of the Trade
  • E-App Checklist
  • On-Site Survey Readiness Checklist
  • How to Conduct a Mock Tracer
  • Mock Tracer Worksheet
  • Comprehensive Organization Assessment
  • Mock Tracer Worksheet: Emergency Department
  • Daily Compliance Checklist
Chapter 3: Working with Data
The Big Idea
Key Concepts
  • Accessing Data
  • Reporting Data
  • Tracking Data
  • Performance Measurement
  • Understanding Data Displays
Tools of the Trade
  • Data Reporting Chart
  • Data Display


Chapter 4: Performance Improvement
The Big Idea
Key Concepts
  • Improvement Process
  • Improvement Infrastructure
  • Improvement Team
  • Improvement Opportunities
  • Improvement Interventions
  • Improvement Recognition
It’s a Challenge
Tools of the Trade
  • Proposed PI Projects Decision Checklist
  • Classification Codes for PI and Reporting
  • RPI Data Collection Template
Chapter 5: Leadership
The Big Idea
Key Concepts
  • Leadership Structure and Responsibilities
  • Safety Culture
  • Leadership and Performance Improvement
  • Operations and Change Management
It’s a Challenge
Tools of the Trade
  • Safety Culture: Organizational Assessment
  • Proactive Risk Assessment
Chapter 6: Staffing
The Big Idea
Key Concepts
  • Sufficient and Well-Trained Staff
  • Staff Qualifications and Competencies
  • Credentialing and Privileging
  • Nursing Services
It’s a Challenge
Tools of the Trade
  • Education Assessment Survey for Managers
  • Education and Attendance Documentation
  • Credentials Review Tracking Worksheet
  • Orientation Competency Assessment and Validation Tool
Chapter 7: Care of the Patient
The Big Idea
Key Concepts
  • Planning and Coordinating Care
  • Assessment and Reassessment
  • Restraint and Seclusion
  • Operative or High-Risk Procedures
  • Patient Rights and Responsibilities
It’s a Challenge
Tools of the Trade
  • Joint Commission Standards Summary Form
  • Discharge Summary Checklist
  • Surgical Safety Procedure Checklist
  • Mock Tracer Worksheet: Patient/Family Education
Chapter 8: Records and Information Technology
The Big Idea
Key Concepts
  • The Medical Record
  • Health Information Security
  • Verbal Orders
  • Informed Consent
It’s a Challenge
Tools of the Trade
  • Health Information Policy Checklist
  • Verbal Order (VO) Policy and Procedure Audit Form
  • Mock Tracer Worksheet: Verbal Orders
  • Informed Consent Form Checklist
Chapter 9: Infection Prevention and Control
The Big Idea
Key Concepts
  • IPC Program and Plan
  • Hand Hygiene
  • Transmission of Infections
  • Health Care–Associated Infections
  • IPC and EC
It’s a Challenge
Tools of the Trade
  • Hand Hygiene / Glove Use Observation Form
  • TST® for Hand Hygiene
  • Environmental Services Checklist: Cleaning of Patient Rooms
  • Infection Control Risk Assessment (ICRA): Matrix of Precautions for Construction and Renovation
  • Endoscope Reprocessing Checklist
Chapter 10: Medication Management
The Big Idea
Key Concepts
  • A System of Processes
  • MM Standards and Other Standards
  • Medication Errors
  • Medication Reconciliation
  • Medication Orders
  • Medication Equipment and Technology
  • High-Alert and Hazardous Medications
It’s a Challenge
Tools of the Trade
  • Medication Management System: Stakeholder Analysis Form
  • Medication Errors Data Review
  • Medication Event Huddle Data Collection Form
  • Medication Reconciliation Card
  • Medication Storage and Security Checklist
Chapter 11: The Physical Environment
The Big Idea
Key Concepts
  • Management Plans and Risk Assessments
  • Safety and Security
  • Hazardous Materials and Waste
  • Medical Equipment and Utilities
  • Fire Safety and Life Safety
It’s a Challenge
Tools of the Trade
  • Emergency Management 
  • EC Management Plan Evaluation Checklist
  • EC Management Plans and Risk Management
  • EC Assessment Checklist
  • Health Care Workplace Violence Overview
  • Environmental Risks for Suicide Checklist
  • Hazardous Materials Inventory Checklist
  • AEM Program Checklist
  • Mock Tracer Worksheet: Life Safety
Chapter 12: Testing and Transplants
The Big Idea
Key Concepts
  • Waived Testing
  • Quality Control Checks
It’s a Challenge
  • Nonwaived Testing
  • Transplants

Tools of the Trade

  • Mock Tracer Worksheet: Point-of-Care Testing (POCT)
  • Mock Tracer Worksheet: Tissue Handling
  • Using FMEA to Improve the Organ Procurement and Transplantation Process

Appendix A: Resources
Appendix B: FSA Risk Charts
Appendix C: Orientation, Training, and Education Requirements
Appendix D: Credentialing, Privileging, Qualifications, and Competencies
Appendix E: National Patient Safety Goals



Payment Options

Payment Options

All Joint Commission Resources products require pre-payment. For your convenience, if you do not have a credit card available, we offer a sales quote/proforma invoice option to assist with initiating your payment.

To take advantage of this option:

  1. Choose your item(s) and add them to your shopping cart. Select "Proceed to Secure Checkout or Create Proforma Invoice."
  2. Enter your billing and shipping details. Select "Continue."
  3. The next screen will be a full summary of your order.
    1. On the bottom right, there is a section titled "Create Proforma Invoice."
    2. Click the "Proforma Invoice" button. (See image below.) 
    3. Within 5 minutes, a sales quote will be sent to your email address with details about how to complete a check or wire transfer payment.

Or contact Customer Service at 877.223.6866 (+1 770 238 0454 outside the US) or via email at to have a proforma invoice created and emailed directly to you.


Related Products

next prev