Meet Kristin Bratcher

Kristin Bratcher serves as the Vice President of Achieve Accreditation. Her responsibilities include business development support, operations management, client relationships and corporate communications. Kristin also offers hands-on accreditation readiness consulting. She holds a bachelor’s and master’s degree in social work from Aurora University. Kristin is celebrating a fifteen-year career in the senior living industry in advancing leadership roles.

Kristin’s desire to help people drew her to her current role. She appreciates working with organizations on their quality and safety to achieve and maintain accreditation, resulting in the best care for residents. One of her favorite parts of her position is working directly with both consultants and clients. “I get to continue to grow my relationships with my clients in addition to providing guidance and education to the consultants too,” she said.

Kristin’s clients appreciate the genuine relationships she builds with them. Tiffany Hall Nursing and Rehab Administrator Dianne O’Sullivan said, “Kristin Bratcher is awesome and never says ‘no.’ She always finds the time to be courteous and kind to staff even when she nudges them towards compliance.”

Throughout her eight years on the team, Kristin not only fulfilled leadership roles, but also grew close with other team members. Vice President Kerri Hackstock said, “The thing I enjoy most about working with Kristin is every task we are assigned to work on, we have fun with it. We get the job done but do not take anything too seriously, which actually makes us more productive and creative.”

Outside Achieve Accreditation, Kristin is a both a wife and a mom of young boys. Her family is the most important thing to her. During her free time, she can be found driving her sons to extracurricular activities or cheering them on from the sidelines. Kristin and her husband are also huge sports fans and attend one away game for the Chicago Bears each year. It is on their bucket list to visit every stadium. Kristin values her balance between work and family and manages to dedicate her full attention to both. “Being able to give my work 110% and then when it’s time to put my mom and wife hat on, giving that 110% too is most important to me,” she said.

Jessica Prucha, BAJ is the Office Manager and Brand Storyteller at Achieve Accreditation. Achieve Accreditation has helped skilled nursing providers and assisted living organizations to obtain and maintain their Joint Commission Accreditation for over 30 years.

2022 New Standards Information: Water Management Program

A Closer Look at Joint Commission Nursing Care Center Standards:

EC.02.05.02- The organization has a water management program that addresses Legionella and other waterborne pathogens.

The new standards implemented January 1, 2022 are designed to focus on immunocompromised patients/residents. The Joint Commission has used expert literature to determine the need for additional standards related to the water management program. This methodology has been supported by the Standards Review Panel assembled by The Joint Commission, Centers for Disease Control and Prevention (CDC) and Centers for Medicare and Medicaid Services (CMS).

Senior Living Facilities often have areas of stagnant water with various PH levels and temperatures. These conditions, overtime, can develop into Legionella and other waterborne pathogens. Exposure to this water while in a senior living facility enhances the risk of an outbreak or an infection from the waterborne pathogens.

The enhanced standards ensure there is oversight of implementation, management and maintenance of the program. As the organization is creating their water management plan, they will need a diagram mapping all water sources along with a water infection risk assessment. This risk assessment will be reviewed for re-approval on an annual basis. Additionally, the organizations must have a plan for addressing the use of water in stagnant locations, along with monitoring protocol and acceptable ranges for the water testing for control measure.

Reference: New Standard for Water Management Program

Kristin Bratcher, MSW is Vice President of Achieve Accreditation. Achieve Accreditation has helped skilled nursing providers and assisted living organizations to obtain and maintain their Joint Commission Accreditation for over 30 years.

Additions and Revisions to Performance Improvement and Leadership Standards

A Closer Look at Joint Commission Nursing Care Center Standards:

PI.02.01.01- The organization has a written plan that describes quality measurement and performance improvement activities.

PI.04.01.01- The organization improves performance.

Performance improvement plans help organizations identify areas or processes of inadequate performance and aid in establishing a path to ensure improvement. Performance improvement plans can be implemented for many different reasons ranging from reducing falls to improving hand hygiene compliance, all of which help create a safe environment for residents and staff.

Effective January 1, 2022, The Joint Commission will be revising and adding to the Performance Improvement and Leadership standards. Revisions will include the need for organizations to incorporate use of an established improvement methodology and its associated tools, and for organizations to develop and maintain relevant and manageable quality improvement plans. To meet these revised and added standards, organizations will need to ensure their written performance improvement plans outline the process(es) that needs improvement, the stakeholders involved, and what performance improvement activities will be involved. The methods for measuring improvement, an analysis of failures and poor performance of the process(es), methods implemented to address deficiencies and methods for sustaining and improving the process(es) will also need to be included in the written performance improvement plan.

Annually, leadership at the organization needs to review the plan for addressing performance improvement priorities. Updates and changes should be addressed at this time. It is extremely important that leadership review performance improvement priorities annually to ensure the proper areas or processes requiring improvement are addressed.

Organizations can choose which methodology they will utilize depending on the performance improvement plan. An example of an accepted performance improvement methodology would be Lean Six Sigma.

Reference: New and Revised Performance Improvement Accreditation Standards

Kerri Hackstock, MA is Vice President of Achieve Accreditation. Achieve Accreditation has helped skilled nursing providers and assisted living organizations to obtain and maintain their Joint Commission Accreditation for over 30 years.