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Joint Commission Behavioral Health Update

October 2009     
In This Issue
Feedback From Recent Surveys
Psychiatric Hospitals: Findings From Life Safety Code Surveys
Barrins & Associates
Barrins & Associates
Greetings to Our Colleagues in Anne Barrins
Behavioral Healthcare! 
Greetings to our clients and colleagues in
Behavioral Healthcare! 
This month, we are providing feedback from the Joint Commission surveys that some of our clients have been through this year. We have identified survey themes common to psychiatric hospitals, Behavioral Health organizations and BH program in medical/surgical hospitals.
In addition, we take a look at what some of the issues have been for psychiatric hospitals that now have a Life Safety Code surveyor as part of their survey team.
We value your feedback on the 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. 

I hope to see many of you next month at The Joint Commission's Annual Behavioral Health Care Conference in Chicago on November 16th through 18th.  If you are planning to attend, please send me an email and I will be sure to look for you!

Regards,Forward this issue
Anne Barrins


Feedback From Recent Surveys
We have had feedback from several clients surveyed this year. The group includes psychiatric hospitals and behavioral health organizations as well as psychiatric units and chemical dependency programs within medical/surgical hospitals. We have analyzed the findings from these surveys and, clearly, there are some common themes emerging across all these settings. The following were key areas of focus in these 2009 surveys and all resulted in Requirements for Improvement for the organizations:
National Patient Safety Goals 
National Patient Safety Goals continue to be a top priority in 2009 surveys. Implementation of the National Patient Safety Goals at the program level was closely scrutinized during all of the surveys. Surveyors expected staff to be familiar with how the National Patient Safety Goals were being implemented within their particular setting. The following were the top compliance issues found on these surveys for National Patient Safety Goals:
Prohibited Abbreviations 
Similar to previous years, several organizations were cited for  prohibited abbreviations. The most common was the use of "qd" in physicians' orders. This was typically found via record reviews conducted during tracers.
Tip: Make sure to keep up your monitoring of prohibited abbreviations, particularly in physicians' orders. If you have a pharmacy filing the orders, they can play a role in monitoring prohibited abbreviations. If you don't, then you need to rely upon chart reviews to catch this one.
Note: Some of the organizations surveyed were using a list of prohibited abbreviations that included more than those required by TJC and they were non-compliant with this expanded list. Remember, if your own policy is more stringent than the standards, TJC holds you to your own policy.
Tip: Keep it simple. Stick to the TJC Prohibited Abbreviations list.
Use of Two Identifiers for Medication Administration 
For organizations that administer medications, surveyors had a fairly consistent approach to reviewing compliance with this National Patient Safety Goal.  First, they asked staff what the policy was for identifying patients/clients prior to medication administration. Then, they found an opportunity to observe nurses administering medications to see if they actually used the two correct identifiers. In addition, some surveyors interviewed patients and asked them if the nurse used two identifiers when administering medication.
Tip: When you conduct internal tracers, try to find opportunities to observe medication administration. Often, the policy for two identifiers is in place but it breaks down in actual practice. Direct observation is the best way to really know how it's working.
Hand Hygiene 
Surveyors were clearly looking for opportunities to observe hand hygiene practices. They also talked to staff during tracers about the requirements for hand hygiene in their particular setting. Here were some of the breakdowns that caused RFIs:
  • No hand washing prior to medication administration
  • Hands washed but not for the required amount of time (very common)
  • In addition to observing hand hygiene, surveyors were also expecting organizations to do their own observations of hand hygiene. Several surveyors asked for data regarding hand hygiene observations. Some organizations had it; others didn't.  
Tip: Develop a process for direct observation of hand hygiene compliance. Select a "peak" time (e.g. medication administration) when the occurrence of hand washing should be high. Use a form to record the number of times that the correct hand washing procedure was followed. Aggregate the data and review at staff meetings to heighten awareness of the importance of hand washing.
Human Resources
The most common theme in the HR arena was the review of files of "specialty practitioners" such as OTs, speech therapists, and dieticians. The focus of the surveyors' review was whether these individuals were having their clinical competence assessed by an individual who was qualified to do that. This was a challenge for those organizations that had only one of that type of practitioner.
Tip: Remember, these types of practitioners need to have input to their competence assessment/performance evaluation from another clinician in their specialty. This can either be from a supervisor or via peer review. If you don't have another one of those practitioners, try setting up an arrangement with another organization for peer review. If that's not possible, see if you can obtain clinical input from another setting where that practitioner works.
Environment of Care 
A new trend that we noticed was increased attention by surveyors to the general cleanliness and upkeep of the environment. Several organizations received RFIs for issued related to cleanliness and maintenance. Sometimes these were cited as EOC issues and sometimes they were cited as Infection Control issues. Here's the short list:
  • Dirty kitchen appliances: microwaves, stoves
  • Dust buildup on ceiling fans, air conditioning and heating vents
  • Patient/client furniture in disrepair
  • Trash on the grounds and/or in patient care areas
  • Broken floor and shower tiles
Tip: Make sure that periodically there is a fresh set of eyes that takes part in the environmental rounds. It's easy for staff that routinely do these tours to get accustomed to the status quo and not spot issues that a surveyor will notice.
In terms of cases selected as tracers, there were definitely some themes that we observed. The following types of cases were frequently selected:
  • Patients/clients with medical problems
  • Patients/clients who had been transferred across levels of care
  • Patients/clients with suicide risk
  • Patients with repeated restraint or seclusion
Tip: If you haven't yet started doing internal tracers as part of your continuous readiness program, start soon. Include these types of tracers and feed back the identified issues into your TJC readiness program.

PPR GroupPsychiatric Hospitals: Findings From Life Safety Code Surveys

In addition to the themes discussed in the article above, there is also the new challenge for psychiatric hospitals of having a Life Safety Code surveyor as part of the Joint Commission survey team. This individual is an engineer who conducts a full Life Safety Code review as part of the Joint Commission survey.  Prior to 2008, in most psychiatric hospitals, compliance with the Life Safety Code was reviewed by either the physician or nurse surveyor who were not experts in this area. Since the introduction of the Life Safety Code surveyor, there has clearly been an increase in the number of RFIs in the Life Safety chapter.
The following are common findings for our psychiatric hospitals surveyed this year:
  • Fire doors propped open
  • Lack of fire rated doors in hazardous areas
  • Obstructed exit corridors
  • Fire wall penetrations
  • Fire doors missing fire rating labels
  • Fire doors missing positive latching hardware
  • Non-rated foam used to seal penetrations
  • Exit signs not visible
  • Excessive undercut on smoke doors
Keep in mind that Life Safety Code non-compliance was the TOP standards compliance issue in 2008, with 45% of hospitals receiving RFIs in this chapter!

For an excellent primer on the Life Safety Chapter and the Statement of Conditions, click on TJC's The New "Life Safety" Chapter
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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.