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Joint Commission Behavioral Health Update

April 2013        
In This Issue
New Client Welcome!
Congratulations Corner
Joint Commission Requirements for Spiritual Assessment in Behavioral Health
Have you Updated Your Sentinel Event Policy?
Barrins & Associates
Barrins & Associates
Greetings to Our Colleagues in Anne Barrins
Behavioral Healthcare! 

It was a pleasure to connect with so many current clients and new colleagues at the National Council for Behavioral Health Conference in Las Vegas this month. The presentations were very stimulating and we had many visitors to our booth in the Expo Hall. Thank you for your interest and your support!


You can view the archived broadcast of plenary sessions by Patrick Kennedy, Doris Kearns-Goodwin, Kathleen Sebelius and others as well as session Power Points on the National Council's website.


This month in our newsletter, our first article covers the topic of spiritual assessment in behavioral health settings, a requirement which has sometimes proven challenging for organizations. Our second article provides information on The Joint Commission's recent change to its Sentinel Event Policy which requires that organizations update their own Sentinel Event Policy.


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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 New Client Welcome!         


Barrins & Associates is pleased to welcome our new client Edgewood Center for Children and Families with headquarters in San Francisco, California.  Edgewood provides community based, residential, school based and youth support services for children and families. In addition, The Edgewood Institute conducts research and evaluation of Edgewood services and those of similar programs nationwide with the goal of continuously improving service to children and families. We are pleased to be working with Edgewood on achieving initial Joint Commission accreditation.

  Congratulations Corner


Congratulations to our client Stars Behavioral Health Group in Long Beach, California who recently underwent their highly successful initial survey by The Joint Commission.! Stars BH Group provides a full continuum of residential and community based mental health services throughout northern and southern California. Because of their complexity, size and geographic range, the organization had a rigorous, two surveyor/four day Joint Commission survey. Their results were outstanding. Congratulations to Stars BH Group on their successful survey preparation and their stellar outcome!

       Joint Commission Requirements for Spiritual Assessment in Behavioral Health   


One of the TJC requirements that has been challenging for some behavioral health organizations is the one relating to spiritual assessment. The specific standards related to spiritual assessment are the following:



Behavioral Health Standards Manual  

  • Standard CTS.02.02.01 Element of Performance # 1 requires that information on the client's "religion or spiritual orientation" be collected as part of the assessment process.  
  • Standard CTS.02.03.07 Element of Performance # 6 applies specifically to organizations providing care, treatment, or services to individuals with addictions. It requires that the organization "obtain the individual's perception of the role of spirituality or religion in his or her life." This is particularly important information for organizations that may make referrals to 12 step programs in which spirituality is a key component.


Hospital Standards Manual  

  • Standard PC.01.02.11 Element of Performance # 5 requires that hospitals assess the needs of patients who receive psychosocial services to treat alcoholism or other substance use disorders and that the assessment include "the patient's religion and spiritual beliefs, values and preferences."
  • Standard PC.01.02.13 Element of Performance # 3 requires that hospitals assess the needs of patients who receive treatment for emotional and behavioral disorders and that the assessment include "the patient's religion and spiritual beliefs, values and preferences."

Organizations can structure the assessment of spirituality in a number of different ways. It can be included as part of the psychosocial assessment or it can be a separate and distinct assessment. There can be some initial screening questions regarding spirituality and then a more in-depth assessment based on the client's need and type of treatment/services provided. Another option is to conduct a spirituality assessment on all clients.


One of the most common TJC survey findings regarding spiritual assessment is that the organization's assessment of the client's spirituality is limited to identifying the individual's religious affiliation and goes no further in assessing how spirituality might be used in treatment. In order to fully meet the intent of TJC's requirements for assessing spirituality, a few key points must be understood.


First, although the terms religion and spirituality are often used interchangeably, there is a difference between religion and spirituality. Broadly speaking, "religion" refers to a set of institutionalized beliefs, rituals, and practices. "Spirituality" refers to a relationship with a higher power that fosters a sense of meaning, purpose, and mission in life. The concepts can be overlapping in that an individual who identifies himself/herself as being spiritual may belong to a particular religion. At the same time, an individual who self identifies as spiritual may not identify with a particular religion. Thus, your assessment tool should go beyond just identifying religious affiliation and include questions on both religious and spiritual beliefs and practices.


Second, the reason for assessing a client's spirituality is to determine if it can be used as a strength to help the individual achieve their treatment goals. Having a strong religious or spiritual sense can provide hope and facilitate coping skills. In addition, many of the 12 Step Groups (Alcoholics Anonymous, Narcotics Anonymous) are grounded in a sense of spirituality and belief in a higher power. Thus, your assessment tool should be geared toward identifying the potential for the client's spirituality to be used as a strength in his/her recovery.


Some of the key pieces of information to be gathered in a spiritual assessment and then used for strengths based treatment planning include the following: 

  • The client's current religious and/or spiritual beliefs
  • The client's current religious and/or spiritual practices.
  • How these beliefs and practices help the client deal with life's challenges
  • Whether the client sees their religion and/or spirituality as a personal strength.
  • How the client sees their religion and/or spirituality as something that could help them achieve their goals  

Once this information has been gathered from the client, it must be reviewed and synthesized by the treatment team. The team, in conjunction with the client, must determine if a sense of spirituality is a personal strength that can be used or potentially developed to help the client achieve their treatment goals. Organizations that utilize a strengths based approach to treatment planning often find that information gathered from the spiritual assessment provides fertile ground for helping the client and the treatment team identify individual strengths that can be used in recovery planning.


Click on Sample Questions for Initial Spiritual Assessment to view questions that you can include in your spiritual assessment tool. Also, to view two excellent articles on this topic by David R. Hodge, Ph.D., an internationally recognized scholar on spirituality and religion click on Spirituality and People With Mental Illness: Developing Spiritual Competency in Assessment and Spiritual Assessment: A Review of Major Qualitative Methods and a New Framework for Assessing Spirituality.

  Have you Updated Your Sentinel Event Policy?


The Joint Commission's Sentinel Event Policy has always focused on unexpected death or injury to individuals receiving care, treatment, or services from a healthcare organization. Recently, TJC expanded its Sentinel Event Policy to include certain harmful events involving staff, visitors, or vendors that occur while these individuals are on the premises of the healthcare organization.  This revision is effective July 1, 2013. The specific change to the policy is that the list of "reviewable sentinel events" has been expanded to include "Rape, assault (leading to death or permanent loss of function), or homicide of a staff member, licensed independent practitioner, visitor, or vendor wile on site at the health care organization."


The rationale for expanding the Sentinel Event Policy is that it promotes improved security and safety throughout the overall environment, regardless of who the victim is. Since these specific types of incidents are now categorized as "reviewable sentinel events," organizations are required to conduct a root cause analysis (RCA) if such an event occurs. If TJC becomes aware of the event, the organization is required to share its RCA, corrective actions, and associated measurement activities with TJC's Office of Quality Monitoring.


Be aware of the following key points related to TJC's Sentinel Event Policy:

  • Reporting a sentinel event to TJC is still voluntary. Organizations are encouraged, but not required, to report sentinel events to TJC.
  • TJC has a definition of "reviewable sentinel events". This means that this subset of sentinel events is subject to review by TJC. There are other types of sentinel events that are not subject to review by TJC.
  • This subset of reviewable sentinel events as defined in the Behavioral Health Standards Manual includes the following:
    • Any occurrence that has resulted in an unanticipated death or major permanent loss of function not related to the natural course of the individual's condition" AND the following occurrences (even if the outcome was not death or major permanent loss of function):
    • Suicide of any individual served receiving care, treatment, or services in a staffed around-the-clock care setting or within 72 hours of discharge from a 24 hour setting
    • Abduction of any individual served receiving care, treatment, or services
    • Sexual abuse/assault (including rape)
    • Rape, assault (leading to death or permanent loss of function), or homicide of a staff member, licensed independent practitioner, visitor, or vendor wile on site at the health care organization (Effective 7/1/13)
  • Note: The Hospital Standards manual (under which psychiatric hospitals are surveyed) has a definition of reviewable sentinel events that also includes occurrences applicable to hospital settings.
  • If TJC becomes aware of a reviewable sentinel event (either through voluntary self reporting or from another source), the organization must do the following:
    • Prepare a thorough and credible RCA and action plan within 45 days of becoming aware of the event.
    • Submit to TJC its RCA and action plan or otherwise provide for TJC's evaluation of its response to the sentinel event under an approved protocol within 45 days of the known occurrence of the event.


For more information on TJC's Sentinel Event Policy, see the Sentinel Event chapter in your standards manual. To review a report on Sentinel Event Data from 1995 to 2012, click on the TJC website

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Barrins & Associates provides Joint Commission and CMS 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.