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Joint Commission Behavioral Health Update

January 2011      
In This Issue
Welcome to Our New Clients!
Effective January 1, 2011: Surveyors Begin Applying the New Care, Treatment, and Services Standards
New In 2011: Patient-Provider Communication Requirements for Hospitals
Barrins & Associates
Barrins & Associates
Greetings to Our Colleagues in Anne Barrins
Behavioral Healthcare! 

We hope that your New Year is off to a productive and exciting start! This month we are providing information on some topics of particular interest as you begin your 2011 continuous readiness efforts.


Our first article discusses the definition of Physical Holds for Children/Youth that is now part of the new Care, Treatment and Services chapter in the Behavioral Health manual.


Our second article outlines the new Patient-Provider Communication requirements that apply to hospitals. Be sure to check out the valuable Resource Guide mentioned at the end of the article.


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. 


Happy New Year!
Anne Barrins

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Welcome to Our New Clients!Welcome - Right


Barrins & Associates welcomes our new clients:

    Aspiranet, South San Francisco, California

    Behavioral Centers of America Ohio Hospital for Psychiatry, Columbus, Ohio

    Behavioral Centers of America Permian Basin, Midland, Texas  

    Hopes of Honorable Youth, Atlanta, Georgia

    Yale-New Haven Psychiatric Hospital, New Haven, Connecticut

Standards REffective January 1, 2011: Surveyors Begin Applying the New Care, Treatment, and Services Standards


If you are an organization or a program that is surveyed under The Joint Commission's Behavioral Health standards, the new Care, Treatment, and Services (CTS) chapter applies to you. In our July 2010 newsletter, we provided a summary of the new requirements in this chapter. If you haven't had a chance to review that article, we recommend that you click on the link to our July newsletter. (Please note that the CTS chapter is no longer on the TJC web site. It is in your 2011 BH Standards manual.)


At TJC's 2011 Behavioral Health Care Conference in November, the new CTS chapter took center stage. Clearly, surveyors will be focusing heavily on this chapter as the 2011 surveys unfold. A topic of major discussion was the new standards on the Physical Holding of Children and Youth (CTS.05.05.01 - CTS.05.05.21). TJC made the following points clear about these new standards:


  • Physical holding is a type of restraint. Physical holding of children/youth is a method of restraint in which a child's or youth's freedom of movement or normal access to her/his body is restricted by means of staff physically holding the child or youth for safety reasons.
    • Note: This definition is also in the 2011 BH Standards manual glossary.
  • The standards on physical holding of children and youth apply to organizations and programs that provide care, treatment, or services to children/youth and use physical holding for behavioral reasons.
  • The 2011 BH standards on Restraint (CTS.05.06.01 - CTS.05.06.35) apply to the following interventions:
    • Mechanical restraint of children/youth
    • Mechanical restraint of adults
    • Physical holding of adults
    • Note: There are no changes in the 2011 Restraint standards from the 2010 Restraint standards.

So, if you do use physical holds as a behavioral intervention for children/youth, be sure to study the new standards and, as needed, modify your current policies and processes to ensure compliance with the new requirements.

Discussion - RNew In 2011: Patient-Provider Communication Requirements for Hospitals

Effective January 1, 2011, TJC is implementing new patient-provider communication requirements in the Hospital manual. The goal is to improve safety and quality through effective communication, cultural competence, and patient centered care. The background is that for many patients, communication with their healthcare provider can be impacted by language, cultural differences, and various impairments (cognitive, visual, etc).


What do hospitals need to do to be in compliance? The following is a summary of the new requirements. We also recommend that you review the specific standards and elements of performance (as referenced below) in the 2011 Hospital Standards manual.


2011 Patient-Provider Communication Requirements

  • Identify the patient's oral and written communication needs "including preferred language for discussing health care." (PC.02.01.21 EP 1) This information must be included in the medical record. (RC.02.01.01 EP 1)
  • Identify in the medical record the patient's race and ethnicity. (RC.02.01.01 EP 28)
  • Communicate with the patient in a manner that meets the patient's oral and written communication needs. (PC.02.01.21 EP 2)
  • Allow a family member to be present during the patient's stay. (RI.01.01.01 EP 28)
  • Prohibit discrimination based on twelve specific features. (RI.01.01.01 EP 29)
  • Provide language interpreting and translation services. (RI.01.01.03 EP 2)
  • Provide information to impaired patients in a manner that meets their needs. (RI.01.01.03 EP 3)
  • Define qualifications for language interpreters; need to assess their competency. (HR.01.02.01 EP 1)

Note: During 2011, surveyors will evaluate the hospital's compliance with these requirements Findings of non-compliance will be included in the survey report. However, during 2011, findings for these new requirements will NOT be factored into the hospital's accreditation decision. TJC is essentially considering 2011 to be a year for hospitals to implement the new requirements and design communication processes that will best improve safety and quality for their patient populations.


There is an excellent resource guide available to download from the TJC web site: Advancing Effective Communication, Cultural Competence, and Patient/Family Centered Care: A Roadmap for Hospitals. It has tools, reference material, and a variety of other resources.

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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.