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Joint Commission Behavioral Health Update

October 2010     
In This Issue
New Client Welcome!
Change to Requirement for Monitoring Response to First Dose of a New Medication
Additional Day of Life Safety Code Surveyor for Hospitals in 2011
Sentinel Event Alert: "Preventing Violence in the Health Care Setting"
Barrins & Associates
Barrins & Associates
Greetings to Our Colleagues in Anne Barrins
Behavioral Healthcare! 

This month we are providing updates on some changes to Joint Commission standards and survey process.


Our first article summarizes the recent change to the requirement to monitor the first dose of a new medication.


Our second article highlights an upcoming change for 2011 regarding the length of Life Safety Code surveys.


Lastly, we call your attention to a recent Sentinel Event Alert that is important for your organization to review.


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


Also, Barrins & Associates is a gold sponsor for the Florida Hospital Association's Psychiatric Patient Safety Conference on November 11th and 12th in Orlando, Florida.  The topic is "Spotlight on Safety: Best Practices in Behavioral Health." We hope to see many of our Florida colleagues at that conference.

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
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Welcome - LeftNew Client Welcome!


Barrins & Associates would like to welcome our new client Macon Behavioral Health System in Macon, Georgia. Macon BH System offers a full continuum of mental health and substance abuse services to children and adolescents ages 5 to 21. Programs include acute inpatient services, a residential treatment program, partial hospitalization, intensive outpatient and outpatient services. You can learn more about Macon BH System at

Med Management RChange to Requirement for Monitoring Response to First Dose of a New Medication

TJC has eliminated the standard and element of performance that had specifically required hospitals to monitor a patient's response to the first dose of a new medication.


Background: For several years, TJC has required hospitals to monitor a patient's response to the first dose of a new medication. The standard is MM.07.01.01 EP 2:

"The hospital monitors the patient's response to medication(s) by taking into account clinical information from the medical record, relevant lab values, clinical response, and medication profile. Note: Monitoring the patient's response to medications is an important assessment activity for nurses, physicians, and pharmacists. In particular, monitoring the patient's response to the first dose of a new medication is essential to the safety of the patient because any adverse reactions, including serious ones, are more unpredictable if the medication has never been used before with the patient."


Effective July 1, 2010, TJC eliminated MM.07.01.01 EP 2 from the Hospital standards manual. This was done as part of a project to remove and/or revise standards that hospitals found to be of questionable value. In discussing this change, TJC indicated that the concept of assessment and reassessment is covered in PC.01.02.01: "The hospital assesses and reassesses its patients." However, this is a much broader standard which allows the hospital to define its process for assessment and reassessment. Thus, it is now up to the hospital to determine the most appropriate process for assessing a patient's response to medication.


Implication: Over the past several years, many psychiatric hospitals have received survey findings related to lack of a process for monitoring a patient's response to the first dose of a new medication. Often, surveyors were looking for a specific procedure in writing. In response, some hospitals developed a procedure for nurses to assess the patient's response within a specific timeframe and required specific documentation of that process. With the elimination of MM.07.01.01 EP 2, hospitals now have the latitude to define the best process for monitoring a patient's response to medications that have been administered.


Survey Readiness Strategy: Keep in mind that TJC always holds the organization to its own policy. So, if you developed a specific policy regarding monitoring first dose of a new medication, you should review that policy and determine what you think is best practice. If you retain a procedure specific to first dose monitoring, you will be held to that procedure during survey.


For details of this and other changes to the Hopsital standards, see the June 2010 issue of TJC Perspectives, page 1. These changes will be included in Update 2 to the manuals which will be mailed out by TJC in mid-October. Updates to the E-dition of the standards manual will be done in December 2010.

Life Safety Code LAdditional Day of Life Safety Code Surveyor for Hospitals in 2011

At the recent Joint Commission 2011 Hospital Executive Briefings Session held in New York, TJC announced that they will be adding an additional day to the Life Safety Code survey of all hospitals including psychiatric hospitals. This will begin in January 2011. Thus, if you had one day for the LSC surveyor in your last survey, you will have two days next time. .


Why the more intense focus on Life Safety issues? Well, four of the five standards most frequently cited as non-compliant for hospitals for the first half of 2010 are in the Life Safety and Environment of Care chapters. There also continues to be a significant disparity between TJC and CMS survey findings in these areas and TJC needs to address this issue.


Survey Readiness Strategy: If you conduct a mock survey, make sure to include a Life Safety Code surveyor.  That surveyor should simulate the agenda for the TJC Life Safety portion of your survey. The surveyor can also help you determine which issues (if any) need to be included as Plans for Improvement on your Statement of Conditions, a critical document that is reviewed during your survey. 



Announcement RSentinel Event Alert: "Preventing Violence in the Health Care Setting"


TJC recently released Sentinel Event Alert 45: "Preventing Violence in the Health Care Setting".


This Alert addresses the topic of the increasing rate of violent crime in healthcare settings. It outlines steps that organizations can take to identify their high risk areas and develop prevention strategies.


Be sure to review this Sentinel Event Alert in the key committees that oversee patient safety within your organization.  TJC requires that organizations review these Sentinel Event Alerts and determine the implications for their organization. As part of that review, it may be helpful to do the following:

  • Review your Hazard Vulnerability Analysis to see if you have addressed the issue of potential violence as a risk for your organization. If not, you may need to update the HVA and include this as a risk.
  • Make sure that your Security Management Plan has been updated to include the procedures you have put in place to minimize the risk of violence within your organization.
  • If violence is rated as one of the top risks in your HVA, you should conduct an emergency management drill to test your response. Remember, your drills need to relate to the risks identified in your HVA.

For an additional resource on this topic, see the October, 2010 issue of TJC Environment of Care News, page 1.

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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.