Meet the Team: Amy Antonacci, MSN, RN
Posted: July 22, 2025
Amy Antonacci, MSN, RN, is a Senior Standards Interpretation Specialist for ACHC Hospital Accreditation (Acute Care and Critical Access). She also serves as an ACHC Surveyor. Amy has been a nurse for 35 years, and her passion is patient safety.
We asked Amy to chat with us about her personal experience, her favorite accreditation standard, and why a simple phone call isn’t so “simple” after all.
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INTERVIEWER: Amy, tell us a little bit about your career path and how you ended up at ACHC.
AMY: I’ve been a registered nurse for 35 years. I was the chief nursing officer (CNO) at a community hospital, and for the last two years of my tenure I was also the system chief nursing officer for the healthcare system my hospital was a part of. My entire career was in the hospital setting before joining ACHC two years ago.
As a CNO, the accreditation department always reported to me. I was very proud of the work that we did at my hospital and welcomed the survey team. We were excited to show the surveyors what we were doing. I love compliance and problem solving. I’m a rule-follower at heart.
INTERVIEWER: You’re an accreditation nerd.
AMY: (Laughs.) Yes! That’s exactly what I am. I love the accreditation process.
My organization was accredited by ACHC, and our survey experience was always phenomenal. I especially appreciated that ACHC was so flexible. We were never afraid to think outside the box, because we knew ACHC would recognize that we were still compliant.
As I approached the last part of my career, I decided I wanted to work for an accrediting organization. And of course, the only one I ever wanted to work with was ACHC.
INTERVIEWER: How’s it going? Are you enjoying the career change?
AMY: I thought I knew a lot about accreditation. And I did know a lot from a customer perspective! But it’s very different from what I expected. There are more rules, technical components, and processes. It’s been quite the learning curve for me.
INTERVIEWER: Since you’ve been on both “sides,” do you have any insight on why some hospitals struggle with accreditation?
AMY: You know, sometimes I hear from hospital personnel, “Our accreditation people try really hard, but they don’t get overall support.” They sometimes feel like they can’t make meaningful accomplishments or get a standard to the compliance state. Which is so unfortunate as it really takes input and support from all key stakeholders to be successful. Support for accreditation comes in many forms. It can be a process, a policy, equipment, capital purchases, or the physical environment…
I understand the hospital’s side of it, too. Sometimes hospitals have significant financial constraints; they struggle to pick and choose what they can do. However, that’s very different from just not supporting what’s required. When accreditation requirements are not understood, appreciated, supported, or followed, it ultimately undermines patient safety.
I’m very passionate about patient safety. That’s my favorite thing to talk about.
INTERVIEWER: So, as an accreditation nerd, do you have a favorite standard?
AMY: That’s like picking a favorite child!
Actually, I’d like to talk about a specific pair of standards. One is for the laboratory, and the other is for radiology (ACH 19.00.21/22.02.02, CAH 06.05.05/06.06.11). But the concept is the same for both.
The premise of these standards is that—for the identified major critical results from radiology and laboratory—the hospital will define what the critical result is, and they will promptly call the doctor and notify them of the result. This is so important from a patient safety perspective, and integral to the continuum of care.
Let’s say, for example, a patient has a chest X-ray. The chest X-ray demonstrates a large mass in the left upper lobe that looks to be necrotic.
Patients expect their doctor to have knowledge about critical test results and not to “accidentally” find the result.
If a result isn’t defined by the hospital as critical, that result is going to be filed in a medical record or sent to the ordering provider. It could be a fax sitting on a desk, or it could reside in an EMR unnoticed. The provider who ordered the test has to remember, “Oh, I ordered a chest X-ray for that patient two weeks ago. Did it get done? Did the office receive the results?” Patients expect their doctor to have knowledge about critical test results and not to “accidentally” find the result.
Providers can receive hundreds of test results for their patients each week. They have to triage appropriately and respond to the critical ones first. There’s so much complexity with EMRs and the transfer of information between the outpatient side of healthcare and hospital’s side. There are many different EMRs in healthcare and unfortunately, they don’t all “speak” to each other yet.
Our standards require the hospital to call the ordering provider and verbally report the critical test result. The provider acknowledges receipt. There is no gray area. That vital information isn’t floating out in Never-Never Land. It’s with the person who can take action on it.
Our accredited hospitals must do their due diligence and close the loop. There’s tremendous flexibility in how that happens, but they must develop a policy and follow it; this ensures critical results are consistently handed off in a safe and standardized manner.
INTERVIEWER: It kind of feels like a phone call is such a small thing to do…
AMY: A phone call does seem like a very small action, but it’s really not. And I’ll tell you why.
I helped develop a pathology critical results policy, and it got complicated very quickly. It ultimately boiled down to, “Okay, who’s going to make the call? Is it the pathologist’s responsibility? Are they required to call every single time?” For this particular project, there was a high volume of critical results to take action on.
For the project, we benchmarked with other facilities and discovered that a well-known teaching hospital had a similar policy. To give you an idea, they had around 30,000 new diagnoses of cancer from pathology results annually. Yet they managed to make all of those phone calls and ensure that the actual critical information and the pathology report was handed off safely, every time.
This hospital system actually had to hire people to make the calls; they created a whole new process! I really admired them for that, because we know that hiring new personnel increases cost. Plus, the notification process didn’t yield new revenue unless the patient returned to that hospital for treatment. They were going above and beyond and doing the right thing to make sure the loop was closed for critical pathology results.
So yes, while that phone call may seem small and insignificant on the surface, it requires manpower, time, and an extremely well-defined, safe process that ensures consistency. Every patient, every time.
INTERVIEWER: Thanks so much for sitting down with us today, Amy. Any parting words?
AMY: I firmly believe that accreditation is the foundation for patient safety and patient rights. And that’s why we do what we do. It’s truly, truly why we do what we do.
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