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Joint Commission Behavioral Health Update

October 2011     
In This Issue
Feedback for Psychiatric Hospitals from the TJC 2012 Hospital Executive Briefing
Barrins & Associates
Barrins & Associates
Greetings to Our Colleagues in Anne Barrins
Behavioral Healthcare! 

This month's issue is devoted to feedback for our psychiatric hospital clients from The Joint Commission's 2012 Hospital Executive Briefings. We attended the Executive Briefings session in Dallas and it conveyed important and timely information about TJC's focus for 2012.


If you didn't have a chance to attend Executive Briefings and want a more in-depth review of the topics covered, we offer a customized Power Point session that we can arrange for your team. Just contact me and I can provide information regarding cost and scheduling.


Regards and I look forward to seeing many of you at TJC's Annual Behavioral Health Care Conference on November 16th and 17th in Chicago!


Anne Barrins                                     

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 Feedback for Psychiatric Hospitals from the TJC 2012 Hospital
Executive Briefings

The following are highlights from the 2012 Hospital Executive Briefings session we attended in Dallas, Texas in September. Particular issues relevant to the psychiatric hospital setting are noted. 



New in 2012!


TJC emphasized several new areas of focus for 2012. Pay close attention to these topics as they will receive heightened scrutiny in 2012 surveys.


Second Generation Tracers


TJC began using this more in-depth tracer approach in 2011 and will continue it in 2012. Second generation tracer topics for psych hospitals include cleaning of medical equipment, OPPE/FPPE, and contracted services.  The new topic in 2012 will be clinical information systems and how they support continuity of patient information.

Two important points related to OPPE/FPPE were discussed:

  • APRNs and PAs that provide a medical level of care (i.e. make medical diagnoses and medical treatment decisions) must be credentialed and privileged through the Medical Staff process
  • All LIPs who are privileged by the Medical Staff need to have OPPE and FPPE. This includes non-physician allied health professionals. So, for example, if you choose to privilege social workers, you will need to do OPPE/FPPE for them.

Change to PPR Requirement


Starting in 2012, there will be no PPR required in your survey year. In 2012, TJC will pilot test the Focused Standards Assessment to replace the PPR. The FSA tool will be a subset of standards instead of the full set of standards now required by the PPR. The subset of standards to be used for psychiatric hospitals is yet to be developed.


New Performance Measurement Standard


Starting in 20102, there will be a new PI standard (PI.02.01.03 EP 1) which will require hospitals to achieve an 85% compliance rate on its ORYX accountability measures. By the third or fourth quarter of 2012, this will include six of the seven HBIPS core measures that are now used by psychiatric hospitals. These are the measures related to use of restraint/seclusion, antipsychotic medications at discharge, and post discharge continuing care plans.


Patient Provider Communication Standards


TJC will begin scoring these standards in 2012. (In 2011, they were reviewed but not factored into the accreditation decision.) There will be significant emphasis on these communication standards in the coming year so be sure you have carefully reviewed them. For some helpful resources, see the article in our January 2011 newsletter and the toolkit available on the TJC web site.


New National Patient Safety Goal for Catheter Associated Urinary Tract Infections (CAUTI)


In 2012, there will be a new NPSG on CAUTIs. If you perform catheterizations, you will need to implement evidence based practices to prevent these types of infections. The NPSG allows hospitals to use 2012 to do the planning for the full implementation of these evidence based practices by January 2013.



Hot Topics


The following are hot topics that are proving challenging for psychiatric hospitals in the second half of 2011. Overall, it's more important than ever to understand the relationship of the CMS Conditions of Participation to the TJC standards.


Medication Reconciliation


The medication reconciliation National Patient Safety Goal (NPSG.03.06.01) is being surveyed again. The revised requirements are simpler and more straightforward but make sure you are monitoring compliance with your medication reconciliation process. It's an important issue to cover during tracers.


Condition Level Deficiencies


The findings in your TJC survey report are now crosswalked to the CMS Conditions of Participation. If any Condition level deficiencies are identified during your survey, you will also automatically receive a Condition level deficiency in the Leadership chapter at standard LD.01.03.01 EP 2. Also, if a Condition level deficiency is given, TJC must do a follow-up survey within 45 days.


Medical Staff Bylaws


The revisions to MS.01.01.01 went into effect March 31, 2011 and are being closely scrutinized during surveys. Make sure that your bylaws include all the specific requirements listed in EP 12 - 36 or you will be cited non-compliant.



Most Challenging Standards for 2011      


The trend is clear. Half of the Top Ten standards for the first half of 2011 are in Life Safety and Environment of Care. In addition, the Life Safety Code surveyor now spends a minimum of two days at all psychiatric hospitals. This means that your preparation in these areas needs to be "by the book", well documented and well organized.



Top 10 Scored Standards

in 2011























Within these standards, the most common issues for psychiatric hospitals are:


Record of Care


  • Dating and timing of entries (both for medical staff and non-medical staff)
  • Legibility


  • Verbal orders not authenticated within required timeframe


Infection Control


  • Lack of cleaning/disinfection of stethoscopes, blood pressure cuffs, glucometers

Medication Management


  • Improper storage of meds (including monitoring of med refrigerator temperatures)
  • Incorrect labeling of multi-dose vials (must have 28 day expiration date)
  • Expired meds found in med room

Provision of Care


  • Incomplete nursing assessments
  • Problems with nutritional assessment and follow-up
  • H&Ps not done within 24 hours

Life Safety


  • Fire wall penetrations
  • Fire doors not closing, latching properly



  • Corridor clutter
  • Note: Items in corridor more than 30 minutes = storage


  • Smoke barrier penetrations
  • Smoke barrier doors not properly closing

Environment of Care


  • Documentation of fire safety equipment testing/inspection


If you are interested in a more in-depth review of the topics covered at Hospital Executive Briefings, contact us for information about how to schedule a one hour training session for your organization. We do it via conference call and review a Power Point presentation with your team. That allows you to ask questions and discuss compliance strategies with us. Many of our clients have found it to be a helpful way to keep up with the changes coming in the new year. Contact Anne Barrins for additional information about cost and scheduling.

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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.