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Joint Commission Behavioral Health Update

February 2010        
In This Issue
Congratulations Corner
Make Sure You Have a Process for High-Alert Meds
Take Note: New PI Requirement for Behavioral Health
Barrins & Associates
Barrins & Associates
Greetings to Our Colleagues in Anne Barrins
Behavioral Healthcare! 
It's been a busy start to the New Year with several clients undergoing initial and triennial surveys!  In the spirit of keeping you "survey ready," we are providing information this month on two topics of special interest in 2010.
Our first article deals with how "High Alert Medications" are being surveyed and how to ensure compliance with this requirement. Our second article discusses the new requirement in the Behavioral Healthcare standards for collecting data from clients regarding their involvement in the treatment planning process.
Also, we hope to see many of you at the annual meeting of the National Association for Psychiatric Health Systems in Washington D. C. on March 8, 9, and 10. Barrins & Associates is a sponsor of the conference and we invite you to come visit us at our booth!
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
CongratulationsCongratulations   Congratulations Corner
Congratulations to three of our clients who received their initial Joint Commission accreditation in the last quarter! All of these organizations followed a very planful process for achieving accreditation. They each completed a self assessment, implemented their action plan and conducted a mock survey as the final step in their preparation process. Based on this preparation, their staff approached the survey with increased confidence.  All had highly successful survey results and are proud to have achieved the "gold standard" of Joint Commission accreditation. We look forward to working with all of them on their Continuous Readiness programs!
                       Community Care Hospital, New Orleans, Louisiana                  
                       Eating Disorder Center of Colorado, Denver, Colorado 
                       Seneca Center, San Leandro, California
Medical Device - leftMake Sure You Have a Process for High-Alert Meds

Feedback from recent Joint Commission surveys indicates that surveyors are focusing on how psychiatric hospitals handle "high-alert medications." Although this standard has been around for awhile, it has received increased scrutiny from surveyors in the past year.  This has prompted questions from several clients:
How does TJC define a high-alert medication?
A high-alert medication is defined as a medication that bears a heightened risk of causing significant harm to the patient when the medication is used incorrectly. 
What types of high alert medications are used in psychiatric hospitals?
Examples of high alert medications sometimes used in psychiatric hospitals include insulin, clozapine, controlled medications and anticoagulants. 
What does TJC expect the hospital to have in place regarding these high-alert medications?
, TJC requires that the hospital identify in writing the high-alert medications that it uses. So, this means that there must be a list of high-alert medications.
Second, the hospital must identify the processes it uses to reduce the risk of these medications being used incorrectly. These processes are the risk reduction strategies that the hospital has implemented to reduce the risk of an error being made with these medications. For example, some hospitals require a two-person check for insulin. Another example is the close monitoring of lab values for patients taking clozapine.
The relevant standard is MM.01.01.03:
"The hospital safely manages high-alert and hazardous medications."
EP 1: The hospital identifies in writing its high-alert and hazardous medications.
EP 2: The hospital has a process for managing high-alert and hazardous medications.
EP 3: The hospital implements its process for managing high-alert and hazardous medications.
(Note: EP # 3 is a Direct Impact element of performance.)
How do surveyors assess compliance with these requirements for high-alert medications?
Surveyors typically ask nursing staff about this topic when doing tracers; frequently when they are visiting the medication room on the unit. They look for staff awareness of which medications have been identified as high-alert and how these medications are managed to prevent errors. The topic is also frequently discussed in the Medication Management interview that takes place during the survey. 
What types of problems have psychiatric hospitals encountered in the area of high alert medications?
The following have been common problems:
  • Lack of staff awareness of what the hospital's high alert medications are
  • Having a list of high-alert medications but nothing more; no specific processes for managing these meds to reduce the chance of an error
  • Lack of a written list of high-alert meds and a policy for handling them
  • Inconsistency from unit to unit regarding staff knowledge of this topic
  • Confusion between high-alert meds and look-alike sound-alike drugs
What is the best strategy for compliance with the high-alert meds requirement?
We recommend the following steps to ensure hospital-wide compliance:
  • Review the ISMP (Institute for Safe Medication Practices) list of high-alert meds at
  • Identify those that are used at your hospital.
  • Determine the procedures you will implement to minimize the risk of these meds being used incorrectly; e.g. special storage, labeling, or administration procedures.
  • Have your Pharmacy & Therapeutics Committee approve the list and the procedures.
  • Train your staff on the list and the procedures.
  • Develop an easy-to-read poster listing the high-alert meds and your strategies.
  • Display the poster in all medication rooms for easy reference.
  • Review the list annually to see if it needs to be updated.
Follow this approach to assure that your staff is not caught off guard when asked about high-alert medications during your next survey.
Treatment Team PNGTake Note: New PI Requirement for Behavioral Health
The 2010 Behavioral Health Standards have a new requirement for data collection in the Performance Improvement chapter. It's PI.01.01.01 EP #16. It introduces a new requirement for behavioral health organizations/programs to collect data on two questions:
  1. Were clients asked about their treatment goals and needs?
  2. Were clients asked whether their treatment goals and needs were met?
The standard reads as follows:
PI.01.01.01 "The organization collects data to monitor its performance."
New EP 16: The organization collects data on the following:
  • Whether the individual served was asked about treatment goals and needs
  • Whether the individual served was asked if his or her treatment goals and needs were met. 
The most likely vehicle for collecting this data would be through your organization's client satisfaction survey. However, prior to incorporating these questions into the satisfaction survey, each behavioral health organization/program will need to examine the mechanisms they are using to involve clients in the treatment planning process. Some questions to consider:
  • Are we using a model that supports clients being involved in developing their treatment plans?
  • Has staff been trained to actively engage clients in the treatment planning process?
  • What efforts do we make to ensure that clients are truly involved in treatment planning?
  • Do clients and family members attend treatment planning meetings?
  • Do we prepare clients and families to participate in treatment planning meetings?
  • Have we asked clients about how our treatment planning process could be improved?
Once your organization's approach to client involvement in treatment planning has been defined, it will be easier to meet this new requirement for collecting data regarding how clients were asked about their treatment goals and whether these goals were met. This feedback from clients and families could provide very useful input for making improvments to your treatment planning process.
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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.