November 2022 Newsletter

In the News This Month

Greetings Everyone,

We hope that each organization had a great time last month celebrating National Healthcare Quality Week!  We thank each and every one of you for working diligently to improve the safety and quality of care your organization delivers.

This month our focus continues on keeping you aware of items of concern we are seeing in the field, and to which regulatory surveyors are heavily focused on..

Sterile instrument safety, specifically the use of instrument identification tape and the weight of the instrument containers are two areas that accrediting and regulatory agencies are again citing.  Our feature article, “Instrument Taping and Tray weights - Let's Talk Sterile Processing,” by Denise Smith highlights the pitfalls that can occur when taping is used, and tray weight is not considered as a component of the processing procedures.  Denise also offers best practices for optimal safety to avoid patient harm.

Our Observations from the Field series would not be complete without including Environment of Care and Life Safety concerns to be aware of. Pat Cook’s article, “Environment of Care & Life Safety Observations from the Field” touches on findings in these two areas which often are frequently cited and carry considerable risk.

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

Surgical instruments coded with tape

Nov 1 2022

Observations from the Field – Let’s Talk Sterile Processing
The Sterile Processing Department is the glue that holds the Operating Room, invasive procedure, and procedural areas of the hospital together. They are like the stage crew for a Broadway play. If Sterile Processing is not working effectively and efficiently, many areas of the organization will not be able ...
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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.

Healthcare Accreditation & Regulatory Consultant Denise Smith
Hospital hallway with clutter

Nov 1 2022

Environment of Care, Life Safety Findings – Observations from the Field
Our newsletter series, Observations from the Field would not be complete if we did not include an article on the Environment of Care and Life Safety findings being cited both during official surveys and commonly found during our mock surveys at organizations. Findings in these two areas often trigger ...
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About the Authors

Patricia Cook, B.S., R.Ph, HACP, GRCP

Pat Cook is a Senior Consultant and Head of Consulting Services at Courtemanche & Associates. Working in collaboration with the C&A Leaders, Pat manages Courtemanche & Associate’s business development initiatives and oversees the clinical delivery of services and support. With her extensive healthcare experience, Pat serves as a knowledgeable resource to new and existing clients, helping to guide them through their accreditation and regulatory needs.

Patricia Cook Consultant & Author

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

Oct 5 2022

Healthcare Disparities & Inequities
This month’s C-APPs offering has bundled several great resources and tools together to assist your organization in addressing Disparities and Inequities?
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October Focus

Healthcare Disparities & Inequities

This month's package includes:

  • Healthcare Disparity & Inequality Initiative Checklist
  • Sample Job Description
  • AHC Health-related Social Needs Screening Tool
  • AAFP Social Needs Screening Tool
  • Additional Resources

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:

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