June 2022 Newsletter

In the News This Month

Greetings Everyone,

Organizations often spend months preparing for their TJC Triennial Survey but once the survey is complete, what do you do next? Our feature article, "After Your TJC Survey," by Senior Consultant, Denise Smith outlines the TJC accreditation decisions an organization can receive as well as providing other essential information about the after-survey work that must occur.

This month, we are also continuing our article series "Observations from the field." Authored by Senior Consultant, Chris Pratt, "Good Infection Prevention starts with the Environment" focuses on recent findings from both actual and mock surveys such as expired supplies, food along with some suggestions on how to approach these problem areas.

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

Action Plan Check List

Jun 1 2022

Next Steps After Your Joint Commission Survey
Your accreditation survey is over! You are tired but relieved, and now it is time to respond to the deficiencies found in your organization. What do you do next? Hopefully, you did not receive any Immediate Threat to Health and Safety (ITHS) citations. If you did, this is what ...
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About the Authors

Joseph Esch, MBA CHFM

Joseph Esch is a Life safety surveyor and consultant. He is trained under the HFAP Acute Care and Critical Access Hospital requirements, as well as The Joint Commission accreditation requirements for the physical environment, fire safety, Life Safety Code®, and Emergency Management chapters. Joseph has 14 years in healthcare, his primary focus is the operations, plant and the physical environment. He has assisted in the planning and initial startup of facility programs in several acute care facilities, including the implementation of CMMS, compliance program, capital forecasting, and facility condition indexing and has been chairman of the EOC committee. He currently holds a Certified Healthcare Facility Manager certification issued by the American Hospital association in 2015 and is a member of the American Society of Healthcare Engineers and the local chapter of Chesapeake Area for Healthcare Engineers.

Denise Smith, Senior Consultant
Hospital Hallway

Jun 1 2022

Infection Prevention Starts With the Environment – Observations from the Field
One of the most common observations our team is making during our survey activity is the challenge that organizations are experiencing with infection prevention, specifically with general cleaning and disinfection.  Having and maintaining an environment that is uncluttered and clean is the basis for all infection control principles.  The ...
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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

C_APPS 2022

Fresh from the Field

Our C_APPS membership provides monthly offerings January through November including regulatory & accreditation tools, resources, tracers, policy checklists, and other key aids to facilitate ongoing success with changing expectations.

C_APPS Healthcare Accreditation Tools & Resources 2022

May 5 2022

Assessing Risk
This month in alignment with our newsletter, our C_APPs offering focuses on the process for assessing risk. As organizations recover from the pandemic, they are challenged with getting their Performance Improvement-Quality Initiatives back up and running.
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May Focus

Assessing Risk

This month's package includes:

  • Risk Assessment Sample Tool
  • Gap Analysis Final Documentation Sample Tool
  • QA-PI Sample Plan: Gap Analysis and Risk Assessment

C_Apps Resources & Tools

C_APPS is an Exclusive Membership Service resource developed by Courtemanche & Associates that provides monthly offerings of regulatory and accreditation tools, resources, tracers, policy checklists or other key aids to facilitate ongoing success with changing expectations.

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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