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Joint Commission Behavioral Health Update

January 2010        
In This Issue
2010 E-dition Available on your TJC Extranet Site
The Handy Portable Version of the Standards
New Medication BoosterPak Published by TJC
New Process for Survey Agendas in 2010
News Flash from the TJC Annual Behavioral Healthcare Conference
Barrins & Associates
Barrins & Associates
Greetings to Our Colleagues in Anne Barrins
Behavioral Healthcare! 
This month we are providing information on a number of resources to support your continuous survey readiness efforts. Read about the updated and improved E-dition, the electronic version of the Joint Commission standards and also find out how to get the most portable version of the standards manual.
Check out the information on the Medication Management Booster Pak recently released by TJC. It's full of insights to how medication management is surveyed.
For those of you who will be surveyed in 2010, be sure to read about changes to how your survey agenda will be developed.
Lastly, there are some News Flashes from the Behavioral Healthcare Annual Conference that I attended in November. See the changes under discussion for the PPR and standards for psychiatric hospitals. 

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. 

Regards,Forward this issue
Anne Barrins
PPR Picture Left2010 E-dition Available on your TJC Extranet Site
Be sure to visit your TJC Extranet site and check out the 2010 E-dition. (Click on The Joint Commission Connect on the TJC home page.)  The E-dition is the electronic version of the standards that is available to every accredited organization. The 2010 E-dition came out December 17th and is very user friendly.
The E-dition contains the standards that are specifically applicable to your organization. For example, if you are a psychiatric hospital that has a Partial Hospital Program surveyed under Behavioral Health standards, your version of the E-dition will contain both the 2010 Hospital standards and the 2010 Behavioral Health standards.
The following are some of the useful features of the E-dition: 
  • It's "searchable." You can enter a phrase (such as "informed consent") and it will search the standards/elements of performance and display those that reference that particular topic.
  • There is a crosswalk from the CMS requirements to the corresponding TJC standards/elements of performance (very useful for psychiatric hospitals.)
  • For BH organizations: There is a Service Profile which allows you to display standards for specific programs and types of services. For example, if you want to display the standards for only residential programs, you can do that.
  • The E-dition is automatically updated when there is an update to the standards.
  • There is a handy "What's New" option that displays all the standards/EPs that have changed since the last update to the E-dition. 
The Handy Portable Version of the Standards

Don't forget that there is a handy portable version of the standards available from Joint Commission Resources. It's the small, spiral bound version of the standards (fondly known as "The Baby Book.) It's much more portable than the large standards manual and whenever I am using mine, people ask me how to get one. You can order it from JCR by clicking on the Publication # below:
2010 Hospital Standards: Publication # HS10  $139
2010 Behavioral Health Standards: Publication # BHCS10  $110
MedicalNew Medication BoosterPak Published by TJC
Be sure to check out the new Medication Management BoosterPak compiled by TJC. It's available on your TJC extranet site (click on The Joint Commission Connect on the TJC home page.)
The BoosterPak contains a wealth of information and useful recommendations for tackling challenging medication storage issues. It includes the following: 
  • Implementation suggestions
  • Tips for compliance
  • Information re how the requirement is surveyed
  • Frequently Asked Questions
Medication storage is one of the top ten compliance issues for both psychiatric hospitals and BH organizations. We anticipate that it will continue to be a key area of emphasis for all surveys in 2010. So, we strongly encourage you to carefully review the BoosterPak for relevant information and use it as a teaching tool within your organization.
Tip: Be sure to review the section on the need for monitoring the temperature of medication refrigerators in outpatient settings that are closed on the weekend. Note that "the penny in the cup" method of monitoring is not acceptable! 
PPR CalendarNew Process for Survey Agendas in 2010

Our clients being surveyed in 2010 are seeing changes to their survey agendas. That's because the process for developing survey agendas has changed effective January 1st.  Previously, the agenda posted to your extranet site contained specific days and times for each of the survey activities (tracers, interviews, etc.) 
The new process is that the agenda posted to your extranet site does not contain specific days and times for the survey activities. Instead, it contains a list of survey activities that are required and recommended timeframes. The specific agenda will be worked out on the first morning of the survey between you and the surveyors. TJC's goal is to be more sensitive to the needs of the organization and the schedules of survey participants.
We all know that the first morning of the survey can be very hectic and it may be a challenge to get consensus on the agenda based on everybody's schedule. So, we highly recommend that you draft a tentative agenda prior to the survey and present it to the surveyors on the first morning as a starting point. That way, you can work out internal schedule conflicts beforehand and get off to a smooth start.
Tip: If your 2010 survey is the same length as your previous survey, you can use your last survey agenda as a template and work from there. 
For a description of the new process for developing survey agendas, see the January 2010 issue of Perspectives, page 4.
News Flash RightNews Flash from the TJC Annual Behavioral Healthcare Conference
At the annual Behavioral Healthcare Conference in Chicago in November, Dr. Anne Scott Blouin, Executive VP for Accreditation, discussed two items of particular interest that we want to share with you:

News Item # 1: Consideration of Changes to PPR Requirements
TJC is considering changes to the requirements for conducting the Periodic Performance Review. One option under discussion is to ease up on the requirement to do the PPR annually and, instead, have organizations hold a phone conference with TJC six months after their survey and then complete the PPR at the 18 month point.

News Item # 2: Possibility of Distinct Standards for Psychiatric Hospitals
Dr. Blouin informed conference attendees that TJC is considering the development of standards that would apply specifically to psychiatric hospitals. Currently, psychiatric hospitals are surveyed under TJC's Hospital standards which also cover acute care hospitals and don't specifically address the needs of psychiatric hospitals.
We will keep you posted in future newsletters as we get more information on these developments!
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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.