Courtemanche & Associates specializes in healthcare accreditation and regulatory compliance consulting services.

We conduct mock surveys to help hospitals and other healthcare organizations prepare for and respond to surveys from accrediting bodies such as The Joint Commission (TJC, formerly JCAHO), DNV, AAAHC, and others, as well as regulatory surveys by the Centers for Medicare and Medicaid Services (CMS) and state agencies.  Our comprehensive line of  services – onsite consulting services, mock surveys, interim support, virtual consulting services and educational product offerings –  are designed  to assist with survey readiness, improve quality, and enhance patient safety.  Our four-prong consulting approach takes you along each stage of the accreditation and regulatory readiness journey.

A Unique Approach to Service:

As your consulting partners, we take a four-part, collaborative and supportive approach to providing excellent service:

  • Assess: We listen to you and seek to understand your particular needs. We work with you to develop an agenda which addresses what you identify as most pressing.
  • Evaluate: Our team, whether onsite or offsite, will thoroughly evaluate your accreditation and regulatory compliance providing honest, direct feedback
  • Educate: We not only identify the opportunities for improvement, we guide you with real-time education on how to address those needs
  • Mobilize: We leave you with an executive summary of immediate priorities for you to address. Within days, you will have access to detailed findings that you can manipulate in a format which will allow you to mobilize teams and take action

Building relationships and working in partnership allows us to guide you along your readiness journey.

What You Can Expect:

A Team You Can Trust – Our Tenets of Service Excellence

  •  Knowledgeable – our consultants are always current and on top of the most recent requirements, standards and accreditation and regulatory trends
  • Trustworthy – our consultants are experts you can trust to provide transparent, honest, confidential assessments and guidance
  • Reliable –You can rely on our consultants to provide you with their most diligent, accurate and timely assistance

Building relationships and working in partnership allows us to guide you along your readiness journey.

FREE Accreditation & Regulatory Webinar
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Using Accreditation & Regulatory Survey Results to Drive Improvement

Learning Objectives:

At the conclusion of this session, learner will be able to:

  • Identify corrective action elements that are applicable to CMS and accrediting organization processes
  • Identify the impact of repeat findings from previous surveys, including The Joint Commission’s process for a related accreditation decision of Preliminary Denial of Accreditation
  • Apply learnings to the development of robust corrective actions for survey findings

Program Description:

The Centers for Medicare and Medicaid Services (CMS) requires a robust process for responding to deficiencies identified during survey activity – whether that be CMS surveys related to complaints or allegations, or surveys conducted by accrediting organizations with deemed status.  Additionally, healthcare organizations across the continuum are challenged with implementing robust, sustainable change to identified deficiencies.

Additionally, The Joint Commission continues to enhance its processes for all aspects of the accreditation process.   With the advent of TJC’s SAFER MatrixTM, there is the need for more robust analysis of higher risk areas of non-compliance.  In addition, leadership involvement in sustainable change must be demonstrated.  Strategies for development of meaningful corrective actions will be explored and sample Evidence of Standards Compliance will be shared.  Also addressed will be TJC’s increased focus on organizations that have a decision of Preliminary Denial of Accreditation for repeat findings.  Organizations challenged with trends in non-compliance that carry from one survey to the next will be challenged with a more intense timeline for addressing those findings – including a ten-day turnaround on corrective action planning, and ongoing communication between TJC leadership and that of the healthcare organization.

Join this session to learn more about navigating the post-survey process to create robust, sustainable improvement on identified findings and get access to tools and resources to assist in that journey.  This session is appropriate for healthcare organizations across the continuum that receive CMS funding and are provided deemed status by an accrediting organization.

Jill Ryan C&A Healthcare Accreditation & Regulatory Compliance TeamPresenter – Jill Ryan, CPHQ, HACP

Jill Ryan is Chief Executive Officer and a Senior Consultant at Courtemanche & Associates.  In this role, Jill is responsible for the daily operations of the firm and assuring the provision of the mission of the company.  She works with clients to enhance Courtemanche & Associates’ offerings through onsite and virtual consultation, web conferencing, and development of new services to meet clients’ needs.

Ms. Ryan has nearly three decades of healthcare administrative and regulatory experience.  She has served as survey coordinator and patient safety officer, facilitating numerous successful Joint Commission surveys, Centers for Medicare and Medicaid Services (CMS) surveys and state surveys.  Jill has worked in senior leadership for the majority of her career and has demonstrated skills in governance and medical staff relations, leadership and management development, facilitation of strategic initiatives and the creation of infrastructure to support operational growth and business goals.

Ms. Ryan has developed numerous unique regulatory compliance tools and resources to assist organizations in accreditation and regulatory success.  Of note, she developed the concept of the “Mini Tracer” which is highlighted in Performance Tracing: A Primer on Tracer Methodology. No stranger to the educational needs of regulatory compliance, Ms. Ryan also developed TJC Boot Camp and TJC 101 to keep organizations on track with accreditation basics and changing regulatory requirements.

Ms. Ryan was also instrumental in developing and implementing the concept of Care Enhancement to operationalize culture change at the operational level of healthcare organizations enhancing compliance and patient care outcomes.  This unique approach modifies organizational dynamics and creates the synergy needed between staff and leaders to attain positive organizational outcomes.

In addition, Ms. Ryan is a Certified Professional in Healthcare Quality and a Healthcare Accreditation Certified Professional.