February 2023 Newsletter

In the News This Month

Greetings Everyone,

With the healthcare industry continuing to experience challenges in many areas, our focus this month revolves around leadership and the significance their level of engagement has in creating and maintaining commitment and expectation for safety at all levels, from frontline providers to managers and executives.

Our feature article, "Leadership Accountability for Survey Readiness", by Chris Pratt, Senior Consultant, speaks to the accountability leadership faces when the organization fails to meet accreditation and/or regulatory requirements, and provides guidance leaders can follow for successful survey outcomes and of the utmost importance, ensuring patient safety.

Our second article, "Culture of Safety, Leadership Responsibility", authored by Senior Consultant, Denise Smith and Associate Consultant, Anne Kelly provides proven strategies in which leaders can build and sustain a culture of safety where patients receive great care and staff can thrive.

We hope you find these articles informative and helpful in assisting you with your ongoing regulatory readiness. Please feel free to reach out to us at info@courtemanche-assocs.com with any topics you would like to see featured or for any service needs you may have.

Hospital Leader congratulating staff

Jan 31 2023

Leadership Accountability for Survey Readiness
Surveys by accrediting organizations are a means to determine if a healthcare organization's performance is aligned with their established standards for quality and safety.  More than ever before, these agencies are holding leadership accountable when the facility fails to meet established accreditation and/or regulatory requirements. In any healthcare organization, ...
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About the Authors

Christopher Pratt, MS, BSN, HACP

Chris Pratt is a Senior Consultant with Courtemanche and Associates with more than 33 years in clinical and leadership experience working in varying healthcare positions from the bedside to the Boardroom. In this role, he is responsible for assessing healthcare organizations’ readiness for licensing, accreditation, and regulatory compliance. He is trained in the survey process, auditing approach and survey outcome determination utilized by The Joint Commission, DNV, Centers for Medicare and Medicaid Services (CMS), and other regulatory agencies and accrediting organizations. He assists organizations with post-survey activities, education, patient safety strategies, and quality improvement initiatives and has experience in various health care settings including acute care, behavioral health, and ambulatory care settings.

Courtemanche & Associates Healthcare Consultant Chris Pratt
Hospital leader engaging with staff

Jan 31 2023

Culture of Safety, Leadership’s Responsibility
What is Culture of Safety? Culture of Safety or Safety culture is viewed as an organization's shared perceptions, beliefs, values, and attitudes that combine to create a commitment to safety and an effort to minimize and/or eliminate harm.  It begins with the attitudes and behaviors toward patient safety that ...
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About the Authors

Denise Smith, RN, MSN, CLNC, HACP

Denise Smith is a Senior Consultant with Courtemanche & Associates. In this role she is responsible for assessing healthcare organizational readiness for licensing, certification, accreditation, and regulatory compliance. She has extensive knowledge in the requirements of The Joint Commission, DNV, and Centers for Medicare and Medicaid services including knowledge in their survey process, auditing approach and survey outcome determination. She also has knowledge and experience in AAAHC and other regulatory and accreditation organizations. She assists organizations with survey preparation, educational needs, post survey activities, patient safety strategies and quality improvement initiatives. Denise has more than 40 years of experience and expertise in Infection Prevention, Sterile Processing, Legal Nurse Consulting, Quality and Resource Management, Clinical Education, in acute inpatient and outpatient care settings.

Clinically, Denise is a licensed Registered Nurse with an extensive background in Infection Prevention and Control for perioperative settings, sterile processing, and quality management. Additionally, she has served as a Certified Legal Nurse Consultant and has aided organizations for EMTALA, Medical-Surgical and Health Care Administration areas of concern.

Anne Kelly, EdD, BSN

Anne Kelly is an Associate Consultant with Courtemanche and Associates. In this role, she is responsible for assessing healthcare organizations’ readiness for licensing, accreditation, and regulatory compliance. Anne is trained in the survey process, auditing approach and survey outcome determination utilized by The Joint Commission, Centers for Medicare and Medicaid Services (CMS), and other regulatory agencies and accrediting organizations. She assists organizations with pre-survey, intra-survey and post-survey activitieseducation, patient safety strategies, and quality improvement initiatives.

With more than 30 years of clinical and leadership experience working in varying healthcare positions, Anne has held various Quality, Accreditation and Patient Safety leadership positions. As Chief Quality and Compliance Officer with Acadia Healthcare, a leading provider of Behavioral Health services in the United States, she led the enterprise-wide Corporate Compliance Program and quality initiatives.

Healthcare Accreditation & Regulatory Consultant Denise Smith
Anne Kelly, EdD, BSN, Associate Consultant

Disclaimer: The information on this website is published in good faith for general information purposes only. This website does not make any warranties about the completeness, reliability and accuracy of this information.

The Joint Commission® is a registered trademark of Joint Commission on Accreditation of Healthcare Organizations. Courtemanche & Associates has no affiliation with this entity.

Courtemanche & Associates | (704)-573-4535 | Email: info@courtemanche-assocs.com

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