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Joint Commission Behavioral Health Update

June 2009     
In This Issue
Effective July 1, 2009: New Restraint and Seclusion Requirements for Hospitals Take Full Effect
Periodic Performance Review Pitfalls and Strategies
Barrins & Associates
Barrins & Associates
Greetings to Our Colleagues in Anne Barrins
Behavioral Healthcare! 
This month we are providing an update and clarification on the CMS related changes to The Joint Commission's restraint and seclusion standards in the Hospital Manual. Be sure to read the clarification regarding how these impact psychiatric hospitals versus behavioral health organizations.
In addition, we are sharing some PPR Pitfalls and Strategies that we hope you will find useful when working on your next PPR.
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MegaphoneMegaphoneEffective July 1, 2009: New Restraint and Seclusion Requirements for Hospitals Take Full Effect


The Joint Commission (TJC) recently issued changes to the restraint and seclusion standards in the Hospital Accreditation Program. These changes apply to hospitals that use TJC accreditation for deemed status from the Centers for Medicare and Medicaid Services. This includes psychiatric hospitals that use accreditation for deemed status from CMS.  Beginning July 1, 2009, these changes to TJC's restraint and seclusion standards will be in full effect. That means these new requirements will now be scored by surveyors and non-compliance will impact the hospital's accreditation decision.
Background: For the first time, TJC had to formally apply to CMS for renewal of its "hospital deeming authority." As part of that process, CMS required TJC to make changes to some standards to align them with the CMS Conditions of Participation.
TJC published the initial revisions in January, 2009 and there were 165 changes. After negotiation with CMS, the number of changes was reduced to 87. These were published by TJC on March 26, 2009 as the Revised 2009 Accreditation Requirements for the Hospital Accreditation Program (see link at the end of this article.)
Hospitals surveyed from April 6 to June 30, 2009 are being surveyed against these new requirements. During this period, non-compliance does not impact their accreditation decision. However, effective July 1, 2009, these new requirements will be fully incorporated into the survey process. Non-compliance will impact the hospital's accreditation decision and will require an Evidence of Standards compliance submission to TJC.
The most significant change for the Behavioral Healthcare field in the new standards is in the area of restraint and seclusion. In a nutshell, here is the change: For hospitals that use accreditation for deemed status from CMS, TJC has replaced the current restraint and seclusion standards in the Hospital Manual with new standards that mirror the CMS requirements for restraint and seclusion.  Specifically, standards PC.03.02.01 through PC.03.03.31have been removed and replaced by new standards PC.03.05.01 through PC.03.05.19.
Exception: If the hospital does not use accreditation for deemed status, the current standards PC.03.02.01 through PC.03.03.31 still apply to restraint and seclusion.
The essence of the change is that the new restraint and seclusion standards are no longer divided into two sets of standards: one for behavioral health and one for medical/surgical care. There is only one set of restraint and seclusion standards. The new standards focus solely on the type of behavior requiring the use of restraint or seclusion and not on the setting in which it is applied.
Are there any new requirements in the new restraint and seclusion standards?
Yes, in the following areas:

  • Written modification to the treatment plan when restraint or seclusion is used (PC.03.05.03 EP 2)
  • In person re-evaluation by the LIP every 24 hours instead of 8 hours for adults and 4 hours for 17 years and under (PC.03.05.05 EP 5)
  • Training requirements for physicians and other authorized LIPs (PC.03.05.09 EP 1)  
  • Definition of what constitutes the uses of medications as a restraint (PC.03.05.04 EP 1)

 Are there any current requirements for restraint and seclusion that are not included in the new standards?
Yes, in the following areas:

  • Staffing levels
  • Initial assessment of the patient regarding restraint or seclusion risks and techniques to help minimize use of restraint or seclusion
  • Informing clinical leaders regarding multiple episodes of restraint or seclusion
  • Patient debriefing following restraint or seclusion
  • Data collection and PI activities related to restraint and seclusion

 What has not changed?

  • Restraint or seclusion is to be used safely and only when clinically justified or warranted by patient behavior that threatens physical safety
  • Restraint or seclusion is based on an individual order
  • Monitoring and evaluation of patients in restraint or seclusion
  • Written policies regarding restraint and seclusion
  • Medical record documentation of use of restraint or seclusion
  • Staff training on the use of restraint and seclusion

Do these changes to the restraint and seclusion standards apply to Behavioral Health organizations that use restrain and /seclusion?
These changes do not apply to Behavioral Health organizations surveyed under the Behavioral Health Manual. The current restraint and seclusion standards in the 2009 BH manual (PC.12.10 - PC.PC.12.90) remain in effect at this time.
TJC plans to update the automated PPR and the E-dition of the standards by July 1, 2009 to include the CMS related changes. They also plan to publish FAQs on the new restraint and seclusion standards in the near future.
For a summary of all the CMS related changes, see the May 2009 issue of Perspectives.
Click below to access resources on the new restraint and seclusion requirements:

PPR CalendarPeriodic Performance Review Pitfalls and Strategies

All accredited organizations have now become accustomed to completing the annual Periodic Performance Review (PPR) required by TJC since 2004. The PPR can be a very valuable tool for keeping your organization in a state of continuous survey readiness. It's the most thorough self assessment you can do to determine your compliance with TJC standards. Once completed, the PPR is the foundation for developing an action plan for full compliance and survey readiness. The PPR is particularly critical for your organization as you approach your anticipated triennial survey.
Some organizations get more value than others from completing their PPR. Over the past few years, we have seen some common "PPR Pitfalls" that organizations can fall into. Try to avoid these when tackling you next PPR:
Pitfall # 1: The "We do that!" Syndrome:
This is when managers sit around the conference table, read the standard and say: "We do that." They don't actually use any observations or data but rather assume compliance. This is risky. Make sure that before you conclude "We do that," you go out and check to see if it's actually being done according to the requirements of the standard.
For example, you know your staff does client education. But, before you score yourself fully compliant, check and see if your clinical records would show that this education is being done.
Pitfall # 2: The "We have a policy on that!" Syndrome:
This is when an organization thinks that because it has a policy in place related to the standard, then it is in full compliance with the standard. Remember, the PPR is asking you to assess not just the existence of a policy but rather implementation of that policy on an ongoing basis. You may have the perfect pain management policy on paper but is the staff consistently implementing the process according to your policy?
Pitfall # 3: The "We've never been cited on that in the past!" Syndrome:
This is when an organization reviews a standard and concludes that they must be in compliance because they have not been cited on it in previous surveys. Don't assume this! The surveyor may simply have missed it. Or, you may have been in compliance at that time but now your performance on that process has changed. Go out and check it out to see how the process is performing today.
Case in point: one organization recently received an RFI because their glucometers did not have two levels of control (PC.16.50 in BH Manual; WT.04.01.01 in Hospital Manual.) They had scored themselves compliant on their PPR but no one had actually checked the glucometers that were being used. Turns out that someone had replaced the previous glucometers (which had two levels of control) with a new model that had only one level of control. Lesson learned: go out and see for yourself.

PPR StrategiesPPR Group
We have found that organizations that use a planful and organized approach to completing their PPR go through their surveys with greater confidence and better outcomes. When working with organizations on their PPRs, we help them organize the effort into the following steps:
  • Identify a "process owner" for each chapter. This person will lead the effort to complete the PPR review on their chapter.
  • Organize chapter groups. They will work with the process owner to review and score their assigned chapter. Sometimes, existing committees can be used as chapter groups, e.g. Pharmacy & Therapeutics Committee for the Medication Management chapter and Infection Control Committee for the Infection Control chapter.
  • Educate the chapter groups. Help them become the "content experts" by reviewing the standards as well as the FAQs on the TJC web site. Share your previous survey reports with the chapter groups so they see what has been problematic on past surveys.
  • Use data to determine your actual level of compliance with the standard. There may be existing data that you can utilize: medical record audits, utilization reviews, findings from tracers, etc. Or, you may need to go out and collect data by reviewing records and doing some new tracers.
  • Develop an action plan for any areas of non-compliance. The whole purpose of conducting the PPR is identifying what needs to be fixed.
  • Keep your leadership team informed of your findings. Have the process owners present the results for their chapters to the leadership team. This shows leadership support for the PPR process and keeps it high on the organizational radar screen.
  • Make sure you have a forum for follow-up on your PPR action plan. This may be through your PI Committee, Joint Commission Prep Committee, or assigned to various existing committees. Otherwise, things get diffuse and issues that were identified go unresolved.

Remember, you are not required to share your PPR with the surveyors during your survey. They cannot ask to see your PPR. They can only ask to see the Measure of Success (MOS) data. This is the data you need to collect for any standards/elements of performance that you scored as non-compliant and that required a Measure of Success (designated by an "M" on the PPR.)
It's a guarantee that if you are thorough and rigorous in completing your PPR, you will have a smoother, more successful survey experience. And, who wouldn't welcome that?

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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.