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Joint Commission Behavioral Health Update

November 2010     
In This Issue
Welcome to Our New Clients!
Psychiatric Hospitals: Be Ready for Increased Survey Focus on Cleaning of Medical Equipment
Infection Control now in Top 10 Standards Compliance Issues for Behavioral Health
New Resource for Residential Treatment Centers
Barrins & Associates
Barrins & Associates
Greetings to Our Colleagues in Anne Barrins
Behavioral Healthcare! 

This month we are covering two Infection Control topics of interest to psychiatric hospitals and behavioral health organizations.


Our first article discusses the increasing TJC survey focus on cleaning and disinfection of medical equipment in psychiatric hospitals.


Our second article highlights some survey challenges related to Infection Prevention and Control programs in behavioral health organizations.


Also, be sure to check out the link to the new resource from the American Academy of Child and Adolescent Psychiatry for Residential Treatment Centers.


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. 


Best wishes for a happy holiday season!

Regards,Forward this issue

Anne Barrins
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Welcome - RightWelcome to Our New Clients!


Barrins & Associates welcomes three new clients:

  • Behavioral Hospital of Bellaire in Houston, Texas provides inpatient and PHP services and is part of the AscendHealth Corporation.
  • Cedar Crest Hospital in Belton, Texas provides inpatient and residential services for children and adolescents and is part of Behavioral Centers of America.
  • New Center Community Mental Health Services in Detroit, Michigan provides a wide range of community based mental health services to the metropolitan Detroit area and has been in operation since 1979.

Exam LPsychiatric Hospitals: Be Ready for
Increased Survey Focus on Cleaning of Medical Equipment


During recent Joint Commission surveys, some psychiatric hospitals have been caught off guard when it came to questions from the nurse surveyor about how they clean or disinfect medical devices and supplies on the units. This topic had never been emphasized in their previous surveys. This time, nurse surveyors were asking staff about the procedures for cleaning items such as stethoscopes, blood pressure cuffs, and glucometers.  During tracers, they also observed if these items were being properly cleaned and stored. They frequently observed staff taking vital signs to see if the blood pressure cuff was cleaned between patients.


Background: In July, 2010, TJC (quietly) announced that the cleaning, disinfection and sterilization of medical equipment, devices and supplies was a problem prone area that would receive "thorough evaluation" during tracers in the second half of 2010 and into 2011.

The relevant Infection Control standard for this topic is IC.02.02.01: "The hospital reduces the risk of infections associated with medical equipment, devices and supplies." EP 1 specifically addresses cleaning and performing low-level disinfection of medical supplies and devices. It is a Direct Impact element of performance.


How to Be Prepared:


  • Identify all of the pieces of medical equipment, devices, and supplies that you have on your inpatient units and in any outpatient programs.
  • Determine which items require cleaning and which items require low level disinfection.
  • Develop written procedures for the cleaning or disinfection of these items. (Surveyors requested written procedures.)
  • Train all appropriate staff in the proper cleaning/disinfection procedures.
  • Include this topic in the internal tracers that you conduct as part of your survey preparation. Ask staff how they clean these items and then observe whether they are following proper procedure.   

An excellent resource on this topic is the CDC's Guideline for Disinfection and Sterilization in Healthcare Facilities.

Chart RInfection Control now in Top 10 Standards Compliance Issues for Behavioral Health

For the first half of 2010, an Infection Control standard (IC.01.03.01) ranked as one of the top 10 standards compliance issues for Behavioral Health organizations. This is in keeping with a trend that we have seen this year for BH surveyors to focus increasing attention on the organization's Infection Prevention and Control program. The following are areas where we have seen some BH organizations run into trouble related to their IC programs:


  • Not having written goals for their IC program
    • IC.01.04.01 requires that you have written infection prevention and control goals. Make sure your goals focus on your specific objectives for this year and that you have measurable targets for the goals.
  • Not having a specific goal related to improving hand hygiene for staff
    • IC.01.04.01 EP 5 specifically requires that you establish a goal for improving hand hygiene compliance among staff. That means that you need to be collecting data on hand hygiene compliance so that you can establish a baseline and then set a target.
  • Not conducting an annual evaluation of the Infection Prevention and Control plan.
    • IC.03.01.01 requires that you conduct an annual evaluation of your IC Plan. You must review your goals and evaluate your progress in achieving them. This evaluation must be communicated to Leadership.
  • Not including outpatient and community based services in the Infection Prevention and Control plan.
    • Several organizations had only included their residential services in their IC Plan and had not addressed their outpatient or community based services. Organizations need to identify infection prevention and control activities that are appropriate for these settings and make sure that these are addressed in the organization-wide Infection Prevention and Control plan.  

Make sure your IC Coordinator and IC Committee are on top of these issues as part of your Continuous Readiness Program!

MegaphoneNew Resource for Residential Treatment Centers 

The American Academy of Child and Adolescent Psychiatry recently published Principles of Care for Treatment of Children and Adolescents with Mental Illnesses in Residential Treatment Centers. The guideline provides direction from an expert panel on a variety of key clinical and administrative issues related to providing care in RTCs.

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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.