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Joint Commission Behavioral Health Update

January 2012    
In This Issue
Use Our Updated Tracer Tools for 2012!
Which New 2012 TJC Requirements Affect You?
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 and resources to support your Continuous Readiness Program in 2012.


Our first article provides our updated 2012 tracer tools based on changes and new requirements in TJC's 2012 standards.


Our second article summarizes the new standards and requirements that go into effect in 2012 for both psychiatric hospitals and behavioral health organizations.


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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Use Our Updated Tracer Tools for 2012! 


We have updated our tracer tools to reflect changes and new requirements in the 2012 Joint Commission standards. There is one tracer tool for psychiatric hospitals that is based on the 2012 Hospital standards. There is another tracer tool for behavioral health organizations/programs that is based on the 2012 BH standards. Feel free to use or adapt our tracer tools as part of your Continuous Readiness Program. The tools are in PDF format. If you would like an Excel version that you can edit, email us and ask for "Excel tracer tools."


A few notes about our tracer tools:


  • They include the most frequently cited standards for psychiatric hospitals and BH organizations as well as common tracer issues encountered during recent surveys.  
  • The tracer tools follow the typical tracer flow used by many surveyors. This includes the following:
    • Unit/program tour
    • Inspection of medication storage area
    • Clinical record review and staff interview 

Common Tracers during 2011 Surveys


Some of the most common tracers selected by surveyors in 2011 included patients/clients in the following categories:

  • Medical problems
  • Nutritional issues
  • Repeated restraint/seclusion
  • Suicide risk
  • Re-admissions to the unit/program
  • Transfers across levels of care
  • Ready-for-discharge

If your organization has a comprehensive Continuous Readiness Program in place, you are probably already conducting internal tracers. If not, consider making that one of your goals for the New Year. For more tips on conducting tracers, see our June 2011 newsletter article "Incorporate Tracers into your Continuous Readiness Program."

Which New 2012 TJC Requirements Affect You?


Make sure you're  ready for the new TJC requirements that go into effect in 2012. The following is a brief recap of new 2012 requirements for both psychiatric hospitals and behavioral health organizations/programs. Click on the links for additional resources.


Psychiatric Hospitals Accredited under Hospital Standards


Effective January 1, 2012:

  • New PI Standard on 85% Compliance Rate on ORYX Measures: PI.02.01.03   
    • This new standard requires hospitals to achieve an 85% composite compliance  rate on their ORYX accountability measures. It does not yet apply to psychiatric hospitals but that is planned for later this year.  Psychiatric hospitals now use the HBIPS (Hospital Based Inpatient Psychiatric Services) measures as their core measures. Since TJC has not yet collected a year's worth of data on HBIPS measures, the 85% requirement does not yet apply. TJC indicated at their November conference that the 85% rule would be effective for psychiatric hospitals around the third or fourth quarter of 2012. (Stay tuned for more info on this topic in a future issue.)
  • New National Patient Safety Goal on Catheter-Associated Urinary Tract Infections: NPSG.07.06.01
    • If your hospital performs indwelling catheter procedures, this new NPSG applies to you. Essentially, it requires that in 2012 you plan for implementation of evidence based guidelines for this procedure.


Effective July 1, 2012:

  • New Patient-Provider Communication Standards
    • These standards were issued in 2011 but do not yet factor into your accreditation decision. TJC has now moved their effective date to July 1, 2012. See our January 2011 newsletter for details.
  • Revised Flu Vaccination Requirements: IC.02.04.01
    • The revised standard strengthens the current requirements for hospitals' flu vaccination programs including incremental goal setting and a written methodology for determining flu vaccination rates. For details, see the TJC Flu Vaccination for Hospitals presentation 


Behavioral Health Organizations/Programs Accredited under BH Standards


Effective January 1, 2012:


  • New Requirements for Health Screening in non-24 hour Programs: CTS.02.01.05
    • This revised standard requires a health screening process with triggers that include determining if the client's most recent physical exam was more than a year ago. See our November 2011 newsletter for details.
  • New Requirements for Health Screening in Residential Programs: CTS.02.01.06
    • This new standard has similar requirements for a health screening process in residential settings and performing physical exams for clients in those settings. See the July 13, 2011 issue of Joint Commission Online for details.
  • New Standards for Primary Physical Health Care: CTS.04.02.19 and CTS.04.02.21
    • These new standards apply to organizations that directly provide primary physical health care or have a formal agreement with a provider for such services. They focus on coordination of services and communication with  primary health care providers. See the July 13, 2011 issue of Joint Commission Online for details.  

Effective July 1, 2012: 


  • New Flu Vaccination standard: IC.02.04.01
    • This new standard requires BH organizations/programs to establish an annual flu vaccination program and set incremental goals for improving flu vaccination rates. For details, see the TJC Flu Vaccination for BH presentation.


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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.