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Joint Commission Behavioral Health Update

March 2012       
In This Issue
New Client Welcome!
Increased Focus on Discharge Planning in Psychiatric Hospital Surveys
BH Organizations: Prepare for New Flu Vaccination Requirements
Barrins & Associates
Barrins & Associates
Greetings to Our Colleagues in Anne Barrins
Behavioral Healthcare! 

It was great to meet and catch up with so many of you at the annual meeting of the National Association for Psychiatric Health Systems in Washington D. C. last week! The agenda was chock full of eminent speakers and the most up-to-date information on issues impacting the Behavioral Health field. Many of our clients are NAPHS members and, for those that are not, we encourage you to consider joining the association. Check out their web site There's a wealth of information on pertinent topics for behavioral health providers.  


In our newsletter this month, we discuss an increasing emphasis we have seen on discharge planning during Joint Commission surveys of psychiatric hospitals.


We are also providing information on the new requirement for organizations accredited under the Behavioral Health manual to begin providing a flu vaccination program for staff effective July 1, 2012.


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 our new client Fred Finch Youth Center with headquarters in Oakland, California. FFYC offers an extensive range of mental health and social services to children, adolescents and families in the San Francisco Bay area and in San Diego. These services include a variety of residential, community based and school based programs. We are pleased to be working with FFYC on achieving Joint Commission accreditation! 

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. 

 BH Organizations: Prepare for New Flu Vaccination Requirements

Effective July 1, 2012, a new standard IC.02.04.01 will be introduced to the 2012 Behavioral Health manual. This standard will require BH organizations to establish an annual flu vaccination program for staff. This requirement has been in place for several years for hospitals and is now being expanded to other accreditation programs including Behavioral Health.


Additional requirements under this new standard include the following:

  • Educate staff about flu vaccine, non-vaccine prevention measures, and diagnosis, transmission, and impact of flu
  • Offer flu vaccine on-site to staff or facilitate their obtaining it off-site
  • Include in your Infection Control Plan the goal of improving flu vaccination rates
  • Set incremental flu vaccination goals consistent with achieving the 90% rate established in the National Influenza Initiatives for 2020 (effective July 1, 2013)
  • Have a written description of the methodology you use to determine flu vaccination rates (effective July 1, 2013)
  • Evaluate data regarding reasons for declining vaccination (minimum annually)
  • Improve your vaccination rates according to your goals (effective July 1, 2013)
  • Provide data to leaders at least annually 

Note the following important points about this new standard:

  • TJC is using a phased implementation approach for BH organizations. Elements of performance # 1, 2, 3, 4, 7, and 9 are effective July 1, 2012. EPs # 5, 6, and 8 are effective July 1, 2013 (as noted above.) This allows time for BH organizations to determine meaningful flu vaccination goals.
  • The flu vaccine is to be offered to contract staff but their compliance rate can be tracked separately from organizational staff.
  • Staff are not mandated to receive the flu vaccine. They can decline it.  

Click on the links below for additional resources:

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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.