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Joint Commission Behavioral Health Update

May 2009     
In This Issue
FMEAS For Partial Hospital Programs: A Clarification
Don't Overlook Your Public Notice About Contacting TJC
Sample Public Notice for APR.09.01.01
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Barrins & Associates
Greetings to Our Colleagues in Anne Barrins
Behavioral Healthcare! 
This month we are providing updates on a few Joint Commission requirements that have sometimes been challenging or confusing for BH organizations.  The first is a clarification regarding the requirement for Partial Hospital Programs to conduct a Failure Mode and Effects Analysis.  The second relates to the requirement for notifying the public about how to report a safety or quality of care concern to The Joint Commission. 
Also, be aware that TJC announced the Top Ten Most Frequently Scored Standards for the first half of 2008 in the March 2009 issue of Perspectives (page 6.) Check it out to see where the recent challenges have been for BH organizations.
We value your feedback on our newsletter. Please email us your comments and tell us what topics you would like to see in future issues.  We look forward to hearing from you!  Also, feel free to forward this newsletter to your colleagues. 

Forward this issueAnne  Barrins
FMEASFMEAS For Partial Hospital Programs: A Clarification

Many psychiatric hospitals, in addition to their inpatient units, operate Partial Hospital Programs. If these PHPs have an average daily census of 11 or more, they are surveyed as a distinct program under the Behavioral Health Standards. The psychiatric hospital, of course, is surveyed under the Hospital standards.
In regard to the requirement to conduct a Failure Mode and Effects Analysis, several psychiatric hospitals have asked if TJC expects the PHP to conduct another FMEA in addition to the one conducted by the hospital.
I recently discussed this question with TJC's Standards Interpretation Group. They provided the following clarification:
If the FMEA conducted by the hospital addresses a process that is in use at the PHP, then the PHP is not required to conduct a separate FMEA. It is expected that the PHP will participate in the hospital's FMEA and implement any redesigns that occur as part of that FMEA.
However, if the FMEA conducted by the hospital addresses a process that is specific to the hospital and not applicable to the PHP, then the PHP must conduct its own FMEA on a high risk process applicable to the PHP.
For example, if the hospital conducts a FMEA on the process for identifying contraband brought onto the unit, this could apply to the PHP since that program may encounter the same issue about contraband. However, if the hospital conducts a FMEA on the medication administration process and the PHP does not administer medications, then this FMEA would not apply to the PHP. In this case, the PHP must conduct its own FMEA on a high risk process within its program and applicable to its patient population.
One cautionary note about FMEAs in general: During recent surveys, some organizations have received a Requirement for Improvement for lack of follow-up on their FMEA. Typically, the scenario is that the organization completed the FMEA and identified several actions to redesign the high risk process. However, they have not implemented the recommended actions or have not adequately monitored and measured to determine whether the actions actually resulted in an improvement.
So, when conducting your FMEA,  it's best to narrow your redesign actions to a critical few and actually measure the success of each one. "It's better to have fewer (redesign) actions that actually get implemented than a myriad of half-addressed or ignored actions," notes Erik Stalhandske, MPD, MHSA of the VA National Center for Patient Safety.
TIP: There is a useful resource book available from Joint Commission Resources on FMEA: Failure Mode and Effects Analysis in Health Care (Item # FMEA02). Click on

TJC NotificationDon't Overlook Your Public Notice About Contacting TJC

During recent surveys, several BH organizations were taken by surprise when they were asked about compliance with Accreditation Participation Requirement .09.01.01 (previously numbered APR 8.)
APR.09.01.01 requires that organizations notify the public about how to contact The Joint Commission regarding concerns about client safety and quality of care. It requires that the organization provide information to the public about how to reach The Joint Commission to convey those concerns.
Some organizations were unaware of this requirement. That's understandable because it's not actually a standard. It's an Accreditation Participation Requirement and these APRs are contained in a separate chapter in the standards manual. So, how are organizations meeting this requirement to inform the public about contacting TJC? 
  • Most are including the information in the handbooks distributed to clients and families.
  • Others are also including the information in their brochures.
  • Many have included the information on their organization's web site.
  • Some have also included it on Clients Rights posters displayed throughout the organization.       

(See a sample public notice at the end of this article.)
Keep in mind that it's also important for staff to know how your organization is providing this information to the public. Staff may be asked about this process during a tracer. Several of our clients have also been questioned about this during the Leadership Interview.
Just how does TJC respond when they receive concerns and complaints from the public? That can range from requesting a written response from the organization to conducting an unannounced survey. To see the criteria that The Joint Commission uses to categorize complaints and determine their response, click on the following link:
One final point: there is a difference between APR.09.01.01 and National Patient Safety Goal.13.01.01. The focus of APR.09.01.01 is on informing the public at large about how to report concerns to the organization's management and to TJC. The focus of NPSG. 13.01.01 is on educating individual clients and families about how to report a concern to the appropriate individual within your organization. It requires giving them information they can use to report an immediate concern to the right person within your organization. Also, remember that NPSG.13.01.01 requires that the organization "encourage clients and their families to report concerns about safety." TJC has emphasized that there is "an active component" to this requirement. To be in full compliance, the organization must demonstrate that they are actively encouraging client participation. 

Sample Public Notice for Reporting Concerns to The Joint Commission

Heartland Behavioral Health is accredited by The Joint Commission. As a Joint Commission accredited organization, Heartland Behavioral Health is required to meet standards related to the quality and safety of client care. If you as a member of the public wish to communicate a concern regarding the safety or quality of care provided by Heartland Behavioral Health, you are welcome to contact The Joint Commission via the following mechanisms:
Office of Quality Monitoring
(630) 792-5636
Office of Quality Monitoring
The Joint Commission
One Renaissance Boulevard
Oakbrook Terrace, IL 60181

If you have questions about how to file your complaint, you may contact The Joint Commission at their toll free telephone number (800-994-6610) between 8:30 a.m. to 5:00 p.m., Central Time, weekdays.
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Barrins & Associates provides Joint Commission consulting services for the Behavioral Healthcare industry. Our clients include both psychiatric hospitals and freestanding Behavioral Healthcare organizations. We specialize in providing Survey Preparation and Continuous Survey Readiness services exclusively for the Behavioral Healthcare industry.  Barrins & Associates was founded by Anne Barrins who was a Joint Commission surveyor for 13 years.