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 http://www.jcrinc.com/ProductDetails1241.aspx.