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Joint Commission Behavioral Health Update

June 2011       
In This Issue
New Client Welcome!
Congratulations Corner
Psychiatric Hospitals: How CMS Impacts Your Joint Commission Survey
Incorporate Tracers into Your Continuous Readiness Program
Barrins & Associates
Barrins & Associates
Greetings to Our Colleagues in Anne Barrins
Behavioral Healthcare! 

Now that summer has arrived in all parts of the country, we trust that many of you are planning some well deserved vacation time. To support your survey readiness efforts even during this more leisurely season, we are providing information this month on two topics of interest.


Or first article discusses the changes in the Joint Commission survey process for psychiatric hospitals as a result of TJC's aligning its standards with the CMS Conditions of Participation. Our second article provides some tips on incorporating tracers into your Continuous Readiness Program. We are also sharing our tracer tools for the Hospital standards and the Behavioral Health standards.


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 a new client: Two Rivers Hospital in Kansas City, Missouri. Two Rivers is part of Universal Health Services (UHS) and provides inpatient psychiatric and chemical dependency services to children, adolescents and adults as well as partial hospital and intensive outpatient services.

CongratulationsCongratulations Corner


Congratulations to our client Puente de Vida in San Diego, California who successfully completed their initial Joint Commission survey this month! Puente de Vida is a specialized eating disorder treatment center that provides residential, PHP, and IOP services. Congratulations to the Puente de Vida team on achieving the gold standard of Joint Commission accreditation! 


 Psychiatric Hospitals: How CMS Impacts Your Joint Commission Survey


As you know, in 2009 The Joint Commission had to re-apply to CMS for deemed status
for the fist time since 1965 when it was originally granted deemed status. As part of that application, TJC had to demonstrate that its Hospital standards covered all of the Medicare Conditions of Participation (CoPs.) TJC cross walked all of the Hospital standards to the Medicare CoPs and also added new requirements to the standards to ensure that all of the CoPs were covered in the TJC standards.


What's the impact of this on your TJC survey?


There are some changes in the survey process that are a direct result of this TJC/CMS alignment. Be aware of these if you're being surveyed this year:

  • The surveyors must review a minimum of 30 medical records or 10% of the average daily census (whichever is greater.) If surveyors don't review 30 open records during tracers, they will review closed records. 
  • Your TJC survey report now includes a crosswalk to the CMS CoPs. Your Requirements for Improvement (RFIs) will be cross referenced to the applicable CoPs. If you are out of compliance with one of the CoPs, the report will identify if the non-compliance is at the Condition level (more serious) or at the Standard level. 
  • If you are out of compliance at the Condition level, TJC will conduct a follow-up survey within 45 days of your accreditation survey. This follow-up survey will focus on corrective action for the Condition level deficiency.
  • If a Condition level deficiency is cited during your TJC survey, you will also receive a Condition level deficiency in the Leadership chapter. Although this approach has long been used by CMS, TJC had not typically used this "double ding" approach. However, CMS required this as part of the negotiation for deemed status.  

So, remember to pay close attention to those TJC standards and elements of performance that are identified specifically as deemed status requirements. Also, when you have a question about the full intent of a TJC standard, check out the companion CMS requirement by using the 2011 CMS - TJC Crosswalk. For accredited organizations, this crosswalk is available on your Joint Commission Connect extranet site. Click on "Continuous Compliance Tools"; click on "E-dition" which is the electronic version of the Hospital standards. Once you are in the E-dition, click on "Crosswalk."  

EOC Assessment 2 - RightIncorporate Tracers into Your Continuous Readiness Program

In our experience helping organizations prepare for Joint Commission surveys, we find that organizations that conduct tracers as part of their Continuous Readiness Program have better survey outcomes than those that don't. That makes sense because 60% of your Joint Commission survey agenda is devoted to tracer activity. Those organizations that do tracers on an ongoing basis are simply more prepared for this approach comes survey time. In addition, doing your own tracers helps you identify systems issues which is exactly where surveyors focus their review.


To make tracers an effective part of your Continuous Readiness Program we recommend the following;


Develop a structured tracer tool

  • Make sure it covers the most frequently surveyed standards.
  • Update the tool as new TJC "hot spots" are identified. 
  • Incorporate other organizational and regulatory requirements if needed.
  • Note: We have two tracer tools that we use: one for psychiatric hospitals (Hospital standards) and one for Behavioral Health organizations/ programs (BH standards.) Click on the links at the end of this article to download these tools.

 Train a small core group to do tracers

  • Make this group the tracer experts.
  • Train for inter-rater reliability. 
  • Use clinicians to do tracers, not just the "QA Cops"
  • Consider using pairs at first; helps people improve their technique

 Explore systems issues during tracers

  • Expand beyond the immediate setting if possible. Trace to the school, the med room, the dining room, the pharmacy.
  • Look at transfers across the continuum and transfers to other settings.
  • Check for communication at junctures where things "fall through the cracks."
  • Review the HR files of staff you encounter during the tracers. Check for competencies, updated training, and current performance evaluations.
  • Interview the patient. See what they know about their treatment plan.

 Incorporate tracer findings into your PI Program

  • Identify corrective actions for non-compliant areas.
  • Prioritize the systems issues identified.   
  • Stick to the schedule for doing tracers.
  • Make Tracer Results a standing item on your PI agenda.

A client who was recently surveyed has been using tracers as part of their Continuous Readiness Program for several years. The PI Director reported that three of the tracers conducted by the surveyor were similar to ones they had done themselves. "The surveyor looked at a nutritional problem, a transfer from inpatient to outpatient, and a client with a behavior management plan. We had recently done tracers on those types of cases and, thankfully, addressed the issues that we identified. We were in much better shape at survey time for having done those tracers."


It's worth the effort to get tracers going within your organization. Feel free to use or adapt our tracer tools

Behavioral Health Tracer Tool 2011 and Psych Hospital Tracer Tool 2011 as part of your Continuous Readiness Program. These are in PDF format. If you would like an Excel version that you can edit, email us and ask for "Excel tracer tools".         

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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.