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Joint Commission Behavioral Health Update

May 2011        
In This Issue
New Client Welcome!
Managing Contracted Clinical Services
Clarification on Medication Reconciliation in the Outpatient Setting
Barrins & Associates
Barrins & Associates
Greetings to Our Colleagues in Anne Barrins
Behavioral Healthcare! 

We hope that spring has reached your region of the country and that the sunny days of summer are not far behind!


This month we are providing an update on The Joint Commission's requirements for managing contracts for clinical services. This is sometimes a challenging area for our clients so be sure to review the latest information in our article.   We are also providing a clarification on how the new Medication Reconciliation National Patient Safety Goal will be applied in outpatient behavioral health settings. 


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. 



Anne Barrins
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Welcome - LeftNew Client Welcome!


Barrins & Associates welcomes our new client University Behavioral Health of Denton, Denton, Texas. UBH Denton, part of Ascend Health Corporation, provides inpatient psychiatric and chemical dependency services to children, adolescents and adults as well as partial hospital and intensive outpatient services.

 Managing Contracted Clinical Services 


Several of our clients have reported increased scrutiny of contracted services during their recent TJC surveys. It's clear that contracted clinical services are high on TJC's radar screen. Let's clarify just what the requirements are for contracted clinical services.


Human Resource Requirements


If your organization has contracted with an individual or an agency to provide clinical services to your patients/clients, you must have verified information of the following for the contracted personnel:

  • Education/training consistent with regulatory requirements and organization policy
  • Licensure, certification, registration (when applicable)
  • Evidence of competence as required by the contracting organization
  • Orientation to the contracting organization
  • Performance evaluation for the contracted personnel
  • Health status information as required by the contracting organization
  • Criminal background check as required by the contracting organization
  • References as required by the contracting organization 

Essentially, there are two different approaches you can take to ensure that you have this verified information:

  • You (the contracting organization) can maintain the information yourself and set up the equivalent of human resource files for the contracted personnel OR
  • You can include in the contract the requirement that the contracted agency maintain this information. 

If you use the latter approach and depend upon the contracted agency to maintain this information, TJC now requires that an audit be conducted either by you or by the contractor to verify that the required information is available. TJC recently clarified that "the audit must include an attestation as to the accuracy of the information. A simple attestation letter indicating that the information is current and on file at the organization site without the audit is not sufficient." See the recently released FAQs on this topic at Hospital FAQ and Behavioral Healtcare FAQ. 


Leadership Requirements


There are also requirements in the Leadership chapter that apply to contracted clinical services. The relevant standard is LD.04.03.09 in both the Hopsital and Behavioral Health manuals. The wording is slightly different in the two manuals but the content is the same. Standard LD.04.03.09 requires the following:

  • Clinical/medical leadership must have input to approving the providers for contracted clinical services.
  • Contracted clinical services must be described in writing. This can be through a contract, letter of agreement or memorandum of understanding.
  • Leadership must approve contractual agreements.
  • Leadership must define written performance expectations for the contracted service and communicate these to the contractor. For example:
    • Contract nutritionist: will conduct nutritional evaluations within 72 hours of referral and send a written report within one week of the evaluation.
    • Contract teachers: will attend weekly treatment team meetings and provide input to treatment team regarding adjustment to the school program
    • Contract nursing agency: will assign nursing staff within two hours of the hospital's request
    • Contract radiology service: all routine radiology reports within 24 hours; all STAT results within 90 minutes of order
  • Leaders must monitor contracted serves by evaluating them against the performance expectations defined in the contact. The ongoing evaluation of the service can be delegated to a manager or a committee within the organization but at least annually leadership must evaluate the contracted service and make a decision about continuing or discontinuing the contract.  

Survey Process


Be prepared for a discussion of clinical contracts during your survey. Have the following material available:

  • A list of all contracted clinical services
  • The actual contract (or letter of agreement) documents
  • Evidence in minutes that medical/clinical staff has had input to the contracts
  • Evidence that leadership has approved the contract
  • Written performance expectations in the contract
  • Evidence that contracted personnel have the appropriate credentials/qualifications
  • Evidence that contracted personnel have received an orientation to your organization
  • Annual review of the contractor's performance as per the performance expectations  

Survey Pitfalls


We have frequently seen things go awry during survey when the surveyor encounters a service provided by a contractor and asks for evidence of that individual's credentials. As described by one client who recently went through this experience: " We assumed  that the hospital was maintaining a copy of the certification for the phlebotomist that they send over here but when we contacted them to produce that documentation during the survey, we couldn't find anyone who knew where it was."

Heads Up: if you are relying on your contractor for this information, test it out prior to your survey to make sure it's easily retrievable.


The other common pitfall is showing evidence of orientation to your organization for contracted personnel. Remember, they need an orientation to your unit, program or service. It can be brief and tailored to their specific role on the unit but some type of basic orientation must occur and be documented. What often happens is that this orientation is done on a somewhat informal basis by the unit manager and often not documented.

Heads Up: Develop a brief orientation checklist that can be used with any contracted personnel. Include clinical documentation requirements, confidentiality, fire safety, infection control, etc.


Bottom Line: Don't forget contracted clinical services when preparing for you next survey! There are requirements in both the Human Resource and Leadership chapters that are important and may receive close scrutiny in your next survey.


Additional Note: The content of this article refers to clinical services provide by contractors who are other than Licensed Independent Practitioners (LIPs.) If an LIP is providing the contracted clinical service on site at your organization, that LIP should go though one of the following processes:

For hospitals: the process for credentialing and privileging of LIPs outlined in the Medical Staff chapter

For Behavioral Health organizations: the process for credentialing and assignment of clinical responsibilities for LIPs outlined in the Human Resource chapter

Clarification on Medication Reconciliation in the Outpatient Setting

As you are all aware, the revised Medication Reconciliation National Patient Safety Goal (NPSG.03.06.01) goes into effect July 1, 2011. There are no new requirements in the new version and the elements of performance are actually simplified from the previous National Patient Safety Goal.


Some readers had a question about the requirement for giving the patient/client a list of their medications at discharge from an outpatient setting in which medications have been prescribed. The wording of the new goal can be a bit confusing because it says:


Behavioral Health Manual: "Provide the individual served with written information on the medications the individual should be taking at the end of the encounter."

Hospital Manual: "Provide the patient with written information on the medications the patient should be taking when he or she is discharged from the hospital or at the end of an outpatient encounter."


Some readers had asked if this was intended to mean that the patient/client should be given a list of their medications at each outpatient visit. We have clarified with The Joint Commission Standards Interpretation Group that the requirement is not to provide the patient/client with a list of their medications at the end of each outpatient visit but, rather, upon discharge from the outpatient setting.

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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.