As reported in our March 2011 newsletter, The Joint Commission received deeming authority from CMS in February 2011 for the two Special Conditions of Participation for Psychiatric Hospitals. This means that psychiatric hospitals that elect to use TJC accreditation for deemed status will now have the survey of these two Special Conditions incorporated into their Joint Commission survey.
As part of this new process, TJC has added two surveyor days to the agenda of psychiatric hospitals that elect to use accreditation for deemed status. For example, hospitals that previously had a nurse and a physician for three days will now have a nurse and a physician for four days. Small hospitals that typically had one surveyor for three days will now have one surveyor (either a physician or a nurse) for five days. TJC has indicated that the additional time is for the surveyors to fully survey the Special CoPs according to the CMS survey process.
So, what are the implications for your upcoming survey?
As you prepare for surveys under this new process, keep in mind that the TJC surveyors now must do patient observations according to the CMS protocol. This protocol includes the surveyor observing the patient a minimum of two times (preferably three) and documenting the following information:
- Date, location, beginning and ending times of observation
- Number of patients and number of staff present
- The modality in progress
- What the patient is doing (regardless of whether or not a scheduled treatment modality is in progress)
- What the patient is actually scheduled to be doing during the time of the observation
- If the modality/ intervention is related to the treatment plan goals and objectives
- Patient's level of participation in the activity
- Presence of disruptive behavior and staff''s intervention, if any
- Surveyor's assessment of the following:
- Was the treatment plan carried out?
- Were the patient's needs met?
- Was the activity individualized to meet the patient's needs?
- Was active treatment provided?
- Did the patient achieve the desired outcomes?
Our clients who have recently been through the new survey process report that their surveyors spent increased amounts of time out on the units observing patients. There was also added emphasis on interviewing patients about their treatment. In addition, there were more interviews with staff about their role in the patient's treatment and their knowledge of the treatment plan.
Survey Strategy: It will be more important than ever for staff to be able to articulate how their interventions and interactions with the patient relate to that patient's treatment plan. Staff need to understand the patient's treatment goals and how their work relates to those treatment goals. For example, if a staff person is observed conducting a group, he/she needs to be able to discuss how the focus of the group was individualized to meet the needs of that particular patient. As you conduct your internal tracers, be sure to interview staff and incorporate these issues into your reviews.
We will keep you posted on developments in this new TJC survey process as they unfold. For the official announcement from CMS and helpful FAQs click on CMS Approval of Deeming authority of the Joint Commission for Psychiatric Hospitals (May 6, 2011).