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Joint Commission Behavioral Health Update
September 2009     
      Newsletter   
In This Issue
National Patient Safety Goals Revised for 2010
Top 10 Standards Compliance Issues for 2008
New 2010 Behavioral Health Standards Available Online
Staffing Effectiveness Data No Longer Required
Barrins & Associates
Barrins & Associates
Greetings to Our Colleagues in Anne Barrins
Behavioral Healthcare! 
 
Now that summer vacations are over, most organizations are returning to their routine flow of business, including Joint Commission readiness. To support your efforts, we are providing updates on several news items that came out over the summer. These include the 2010 National Patient Safety Goals, top standards compliance issues, the 2010 Behavioral Health Standards and the news on staffing effectiveness. 
 
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. 
                                        
Regards and enjoy the fall season in your part of the country!
 
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 National Patient Safety Goals

National Patient Safety Goals Revised for 2010: Some Changes Effective Immediately
 
The Joint Commission just released the pre-publication version of the 2010 National Patient Safety Goals. The good news is that there are no new NPSGs for 2010! However, there are some changes. In some cases, the requirements of the NPSG have been moved into the standards. (This means that the requirement is still in place but istead of being labeled as a NPSG, it is included in one of the standards chapters.) In other cases, the  requirements of the NPSG have been streamlined and re-worded. In still other cases, the  NPSG (or some of its elements of performance) has actually been deleted and its requirements are no longer in effect.
 
TJC indicated that the 2010 changes were in response to concerns from the field about the complexity of the goals and the resources needed for compliance. The 2010 NPSGs go into effect January 1, 2010. However, for any organization surveyed between September and December 2009, surveyors will not be evaluating compliance with the requirements that have been deleted for 2010.
 
Also, NPSG # 8 on Medication Reconciliation is still under revision and will be released later in 2010. As for now, compliance with this NPSG is reviewed during surveys but no RFIs are generated regarding medication reconciliation.
 
The following is a quick summary of the key changes relevant to behavioral health organizations and psychiatric hospitals:
 
NPSG.02.01.01 Read-Back of Verbal Orders
 - 2010: Moved to the standards for Behavioral Health & Hospital programs
 
NPSG.02.02.01 Prohibited Abbreviations
 - 2010: Moved to the standards for Behavioral Health & Hospital programs 

NPSG.02.03.01 Critical Tests
 - 2010 Behavioral Health program: Deleted
 - 2010 Hospital program: Streamlined to focus only on "critical results of tests"; no longer required to define both critical tests AND critical test results
 
NPSG.02.05.01 Hand-off Communication
 - 2010: Moved to the standards for Behavioral Health & Hospital programs
 
NPSG.03.03.01 Look-Alike Sound-Alike Drugs
 - 2010: Moved to the standards for Behavioral Health & Hospital programs
 
NPSG.07.02.01 Sentinel Events Resulting from Infections
 - 2010: Deleted for Behavioral Health & Hospital programs
 
NPSG.09.02.01 Fall Reduction
 - 2010 Hospital program: Moved to the standards
 
NPSG.13.01.01 Encouraging Patient Involvement in Care
 - 2010 Behavioral Health program: EP 1 moved to the standards; EP 4 deleted
 - 2010 Hospital program: EPs 1 & 2 moved to the standards; EPs 3 & 4 deleted
 
NPSG.16.01.01 Rapid Response
 - 2010 Hospital program: Moved to the standards
 
For the complete pre-publication version of the 2010 NPSGs, click on   TJC National Patient Safety Goals
 
The final version of the 2010 NPSGs will be published in the October 2009 issue of Perspectives.


2010 Challenging StandardsTop 10 Standards Compliance Issues for 2008 

The top 10 standards compliance issues for 2008 were released by TJC in July. This data is based on surveys completed through the end of 2008. This is useful data for focusing your ongoing readiness efforts and tracers within your organizations.  The following is a quick summary of the issues relevant to BH organizations and psychiatric hospitals:
 
Hospitals (excludes issues related to med/surg hospitals)
 - Life Safety Code
 - Verbal orders
 - Critical test results
 - Complete/accurate medical record
 - Fire safety equipment
 - Staff qualifications consistent with job responsibilities
 - Medication reconciliation (not being scored in 2009)
 
Behavioral Health Organizations 
 - Medication storage
 - Medication reconciliation (not being scored in 2009)
 - Nutritional screening
 - Treatment planning
 - Policy implementation
 - Clinical responsibilities for LIPs
 - Complete/accurate clinical record
 - Organization-wide safety program
 - Staff qualifications consistent with job responsibilities
 - Suicide risk assessment
 - Prohibited abbreviations
 - Re-privileging every two years
 
For a complete listing of the Top 10 Standards Compliance Issues, see the July 2009 issue of Perspectives, page 3.

 BH Standards Online

New 2010 Behavioral Health Standards Available Online
 
The new BH standads for 2010 are available online at the TJC web site. All of the chapters have now been re-numbered, similar to the re-numbering that took place for the Hospital standards in 2009.  However, the Provision of Care chapter has not been re-numbered and the current (2009) Provision of Care chapter will remain in effect for 2010. This chapter is still undergoing review and revision and TJC does not plan any changes until 2011.
 
For the complete text of all the 2010 Behavioral Health Standards chapters and a tracking of the changes from 2009 to 2010, click on 2010 BH Standards
 
The new standards will remain on the TJC web site until the 2010 BH manuals are distributed in late September or early October 2009.

Staffing EffectivenessStaffing Effectiveness Data No Longer Required

In August, TJC announced that it was formally suspending the requirement for hospitals to collect staffing effectiveness data. The requirement to collect and analyze data on indicators related to staffing effectiveness had been in place for several years. Most hospitals reported that the requirement was burdensome and did not bring any added value to their staffing initiatives. TJC is now considering two different elements of performance that would focus on analyzing staffing issues. These have not been finalized and appear to be much simpler than the previous staffing effectiveness requirements.
 
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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.