Joint Commission Behavioral Health Update

Increased Focus on Discharge Planning in Psychiatric Hospital Surveys

Over the past year, we have seen an increased emphasis on discharge planning during TJC surveys of psychiatric hospitals that use TJC accreditation for deemed status. There have always been discharge planning requirements in Joint Commission standards. However, the focus on this area has intensified since the stricter alignment of TJC standards with the CMS Conditions of Participation. In 2010, TJC added a new requirement that hospitals must have "written discharge planning policies and procedures applicable to all patients." (PC.04.01.01 EP 26.) This is now one of the policies commonly requested by surveyors for the document review session on the first morning of the survey.

In terms of survey process, surveyors have focused both on current patients ready for discharge as well as on recently discharged patients. Sometimes, surveyors have requested a list of patients who will be discharged during the survey and selected one of those for a tracer. In this case, the focus of the tracer has typically been on the following:

• Asking staff about the discharge planning process and "who does what?"
• Reviewing the record for discharge planning documentation including progress notes and the discharge plan
• Observing staff providing discharge instructions to the patient/family
• Reviewing the written discharge instructions given to the patient
• Interviewing the patient/family to determine their understanding of the discharge instructions. When this interview has occurred, the focus has been on their understanding of the medications to be taken at home and the plans for follow-up appointments.

In other instances, surveyors have requested a list of patients discharged within the last week. From this list, surveyors have selected a patient for a post discharge phone interview. As one nurse manager related, "I was quite surprised when the nurse surveyor asked me to call the patient and get his permission to be interviewed by her. She got on the phone, introduced herself and then starting asking him questions about which medications he was taking at home and when he was taking them. She asked if he understood the purpose of the meds and the possible side effects. She also asked him about his aftercare appointments with his psychiatrist and his therapist and when those were scheduled for. I had never experienced this before in a survey. I was very glad that our discharge instructions were so clear and that the patient understood them. We've worked hard on our process for educating patients about their discharge instructions. I guess it paid off!"

Survey Strategy Tips:

• Be sure to formalize your discharge planning process into a written policy/procedure. Specify which staff are responsible for the different aspects of discharge planning and providing discharge instructions; e.g. nursing, social work, case management, etc.
• Make sure that your discharge instructions are in a user friendly format that can be easily understood by patients and their families
• Do a tracer on a patient being discharged to observe how discharge instructions are given. Interview the patient to see how well they understand what they are supposed to do after discharge.
• Conduct some post discharge phone interviews to see how well patients understand and have followed their discharge instructions.

It appears that this emphasis on discharge planning will continue. CMS recently released three new surveyor worksheets for assessing compliance with specific CoPs and Discharge Planning is one of them. (The other two are Infection Control and QA/PI.)  The worksheets are currently being piloted and will be finalized in 2013. The focus of this CMS initiative as it relates to discharge planning is to reduce hospital readmissions.  Click on the CMS Announcement to view the new draft surveyor worksheets.