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Joint Commission Behavioral Health Update

May 2010      
In This Issue
New Client Welcome!
Psychiatric Hospitals: Get Ready to Implement Core Measures
New Provision of Care Chapter to be Released for the Behavioral Health Program
Clarification from TJC: An Approved Abbreviations List is Not Required
Barrins & Associates
Barrins & Associates
Greetings to Our Colleagues in Anne Barrins
Behavioral Healthcare! 

2010 continues to be a very busy and productive year as we work with our established clients on continuous readiness and help new clients achieve initial Joint Commission accreditation.


This month we are providing updates on two significant developments. Our first article gives you the latest information about the new core measures that will soon be required for all accredited psychiatric hospitals. The second article provides a preview of the new Provision of Care chapter for the Behavioral Health Manual. There's also a clarification about what exactly is required by TJC regarding approved abbreviations.

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. 

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Anne Barrins
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Welcome - Left   New Client Welcome!
Barrins & Associates would like to welcome our new client: Puente de Vida of San Diego, California. Puente de Vida is a residential program for the treatment of eating disorders and is working toward initial accreditation by The Joint Commission. You can learn more about Puente de Vida and its services at
Charts - RightPsychiatric Hospitals: Get Ready to Implement Core Measures
It is anticipated that by the end of 2010, The Joint Commission will require all accredited freestanding psychiatric hospitals to implement their new set of core performance measures for inpatient psychiatry. Since 2008, TJC has been working with the National Association of Psychiatric Health Systems (NAPHS) and the National Association of State Mental Health Program Directors (NASMHPD) to develop a set of core measures for inpatient psychiatry. The Hospital Based Inpatient Psychiatric Services Core Measure Set has been finalized and pilot tested. The seven HBIPS core measures are as follows: 
  • Admission screening for violence risk, substance use, psychological trauma history and patient strengths completed
  • Hours of physical restraint use
  • Hours of seclusion use
  • Patients discharged on multiple antipsychotic medications  
  • Patients discharged on multiple antipsychotic medications with appropriate justification
  • Post discharge continuing care plan created
  • Post discharge continuing care plan transmitted to next level of care provider upon discharge
 We recently spoke with Frank Zibrat at TJC who is associate director for ORYX Implementation. He anticipates that TJC's start date for requiring the HBIPS measures may be as soon as October 2010. TJC is awaiting final endorsement of the measures by the National Quality Forum. Once TJC makes the HBIPS core measures mandatory, all psychiatric hospitals will be required to collect data on these measures. These hospitals will no longer have the option of using non-core measures, as they do now. The HBIPS measures will be an option for psychiatric units of general hospitals but will not be mandatory.
One of our clients Dorothea Dix Hospital in Raleigh, North Carolina was a pilot site for the HBIPS Core Measure Set and has been collecting data on the core measures since 2008. They found the implementation process less difficult than anticipated and now use the data as part of their hospital-wide Performance Improvement program. They are also using some of the measures as part of their Ongoing Professional Practice Evaluation for physicians.
The goal of the HBIPS initiative is to create a standardized set of performance measures that will allow psychiatric hospitals to compare their performance with that of similar organizations across the country.
Further information regarding how the HBIPS core measures are defined can be found on the TJC web site in the Specifications Manual for National Hospital Inpatient Quality Measures - HBIPS Core Measure Set.
Team - LeftNew Provision of Care Chapter to be Released for the Behavioral Health Program
The new and revised Provision of Care chapter for the BH manual will soon be released. The chapter has been undergoing review and revision for the last two years and has now been finalized. The chapter has been renamed Care, Treatment, and Services for Behavioral Health (CTS.) The requirements in the new CTS chapter will become effective January 1, 2011. TJC plans to post the pre-publication version of the chapter on its web site this summer. In addition, the June issue of Perspectives will highlight the new CTS chapter.
The CTS chapter contains new requirements and revisions in the following areas: 
  • Physical holds
  • Time-out
  • Level systems
  • Psychiatric advance directives
  • Eating disorders
  • Outcomes assessment
  • Pain screening/assessment
  • Treatment planning
Recommendation: If you anticipate your next TJC survey in 2011, carefully review this new chapter. You will be required to be in compliance effective January 1st, 2011 and some of the changes may require modifications to current processes and policies as well as staff training. 
We will be sure to keep you posted on the impact of the changes in the new CTS chapter in upcoming issues of our newsletter.
Clarification from TJC: An Approved Abbreviations List is Not Required 
TJC has clarified that they are not requiring organizations to have a list of approved abbreviations. This applies both to psychiatric hospitals accredited under Hospital standards and to Behavioral Health organizations accredited under BH standards.  See the details below as stated in the April 21st edition of Joint Commission Online: 
"Clarification of IM.02.02.01 on abbreviations, acronyms, symbols, and dose designations:
As part of the Standards Improvement Initiative, the National Patient Safety Goal on abbreviations not to use was moved to the standards and incorporated into information management standard IM.02.02.01 element of performance 2, and the language was revised. Organizations were confused by the new language, which seemed to imply that organizations had to create lists of approved abbreviations, acronyms, symbols, and dose designations. This was not the intention of the revision. Effective July 1, 2010, IM.02.01.01 EP 2 will be revised back to the 2009 language and will state: The organization uses standardized terminology, definitions, abbreviations, acronyms, symbols, and dose designations. For more information, see the Standard FAQ that provides guidance on compliance. (Contact: Maureen Carr,"
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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.