Physical Environment Gap Analysis Self-Assessment — DNV & TJC | 83-Item Workbook
Every accredited facility is expected to know exactly where its Physical Environment programs stand. Most don't — until a survey tells them.This is the self-assessment I wish every facility ran before the surveyor arrived. It walks all eight Physical Environment program areas, item by item, scores each one, and shows you in a single dashboard where you're solid and where the gaps are — while you still have time to fix them.WHAT'S INSIDE An 83-item guided self-assessment across all eight program areas: Documentation, Safety Management, Life Safety, Hazardous Materials & Waste, Security, Utilities, Emergency Management, and Medical Equipment. Simple Met / Partial / Not Met scoring on every item, with room for notes and evidence. An auto-calculating Summary Dashboard that rolls your scores into a clear picture — by area and overall — so your biggest gaps rise to the top. A START HERE guide and a Facility Info tab so the whole thing is ready to use in minutes. WHO THIS IS FORSafety officers, EHS managers, facilities directors, and compliance leaders at hospitals, critical access facilities, surgery centers, behavioral health organizations, and clinics — anyone who owns survey readiness and wants to find the gaps before someone else does.WHO BUILT ITI'm Laura Speary — DNV CHOP, EP-MESH, ASC. I spent 18+ years leading healthcare EHS & Life Safety programs (26+ years in healthcare) across a multi-facility North Carolina health system, most recently as Regional Manager, Environmental Health & Safety. I built this from the same gap-analysis process I ran inside a real health system, through surveys under both TJC and DNV: Find the Gaps. Strengthen the System. Prepare the Organization.HOW IT WORKSOpen the workbook → start on the Facility Info tab → work each section, scoring as you go → read your results on the Summary Dashboard → act on the Not Met items first. Reuse it every year and before every survey.One honest note: this is a professional self-assessment tool, not a consulting engagement, and it doesn't replace a formal survey. What it does is make sure you've looked — thoroughly and honestly — before one happens. If you'd like a second set of eyes, a free 30-minute discovery call is at harborlightsafety.com.WHEN YOU'RE READY FOR THE NEXT STEP Physical Environment Management Plan Package — $495. All seven management plans, plus the annual evaluation system. PE/EOC Governance & Accountability Bundle — $195. Committee charter, accountability matrix, and companion tracker. Behavioral Health Physical Environment Risk Assessment — $145. 78 scored items across 8 risk categories, including ligature risk. Complete Physical Environment Program Library — $795. Everything HarborLight makes, bundled. HarborLight Safety LLC is an independent consulting practice. It is not affiliated with, endorsed by, or accredited by DNV or The Joint Commission.
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