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Joint Commission Behavioral Health Update

May 2013         
In This Issue
Congratulations Corner
TJC to Offer New Certification for Behavioral Health Home
Conducting and Documenting Risk Assessments
Barrins & Associates
Barrins & Associates
Greetings to Our Colleagues in Anne Barrins
Behavioral Healthcare! 


We hope that spring has reached your region of the country and that the sunny days of summer are not far behind!


This month we are providing information on an exciting new project underway at TJC to develop a certification for Behavioral Health Homes. Our first article highlights some of the key features of the proposed standards for BH Homes. Our second article deals with the topic of proactive risk assessment. We cover the 7 Step Model of risk assessment that TJC has put forth and offer some additional strategies for conducting a thorough risk assessment.


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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  Congratulations Corner 


Congratulations to our client San Diego Center for Children who recently achieved their initial Joint Commission accreditation! San Diego Center for Children provides a wide array of mental health and academic services including day treatment, outpatient counseling, a K-12th grade school program, residential treatment and foster care. They have been preparing for TJC accreditation for the past year and achieved highly successful results on their initial survey. Congratulations to the San Diego Center for Children team on achieving the gold standard of Joint Commission accreditation!

     TJC to Offer New Certification for Behavioral Health Home


If your organization is currently providing (or considering) an integrated model of delivering primary physical and behavioral health services, you may want to consider the new certification that TJC will be offering for Behavioral Health Homes. This new certification option will be available beginning January 1, 2014 to organizations accredited under the Behavioral Health standards.


A major impetus for the development of Behavioral Health Homes is the Affordable Care Act which has enabled many states to develop such homes. The "homes" are not residential settings or physical locations but rather a service delivery model that integrates physical health care services with behavioral health services to improve quality of life by addressing the needs of the whole person.


TJC has developed proposed standards for the Behavioral Health Home certification and plans to make the pre-publication standards available this summer. Some of the key provisions of the proposed standards are as follows:

  • Physical health assessment within 30 days of admission
  • Screening for chronic physical health conditions
  • Inclusion of physical health care goals and self management goals on care plan
  • Identifying health literacy needs
  • 24 hour access to contact the Behavioral Health Home
  • An integrated care team and team coordinator
  • Staff education on chronic physical health conditions
  • Use of clinical practice guidelines or evidence based practices
  • PI data on disease management outcomes, access, and client satisfaction  

TJC is working closely with state authorities to acquire recognition for the new Behavioral Health Home certification. This recognition would help meet state Medicaid requirements and improve the reimbursement structure for these services. To learn more about the Behavioral Health Home initiative and organizations providing an integrated approach to physical and behavioral health services, check out The Joint Commission BHC News Issue One 2013.

EOC Assessment 2 - Left

  Conducting and Documenting Risk Assessments


As Joint Commission surveyors conduct tracers during your survey, they are on the look-out for features in the environment that potentially create a safety risk for your clients. In particular, environmental suicide risks are frequently cited in surveys of psychiatric hospitals, psychiatric units of acute care hospitals, residential behavioral health programs and sometimes even in outpatient behavioral health settings. Examples of issues cited on surveys include use of plastic trash can liners, loopable hardware in bedrooms and bathrooms, and non-breakaway rods in closets and showers.


When these risks are identified, the surveyor typically asks if the organization has conducted a risk assessment on the issue. All too often, the organization is unable to demonstrate (and document) that they have conducted a formal risk assessment, analyzed the results and made an informed decision about how to address the identified risk. As a result, the organization is cited as non-compliant with the following standard:


EC.02.01.01 (in both the Hospital and BH manuals) "The hospital/organization manages safety and security risks."

EP 1: "The hospital/organization identifies safety and security risks associated with the environment of care."

EP 2: "The hospital/organization takes action to minimize identified safety and security risks associated with the physical environment."


So, how does one go about conducting a risk assessment on a particular safety issue that has been identified? TJC published an excellent article on this topic in the March 2013 issue of Perspectives titled "Risk Assessment Process: A Seven-Step Approach". One of the examples they used was the issue of exposed plumbing in a Behavioral Health Unit (which has been cited on several of our clients' surveys.) They provided the following example of using the 7 step model to conduct a risk assessment on this issue:


Step 1: The issue: Can we have exposed plumbing in a BH unit?


Step 2: Arguments supporting "yes"

  • Maintains a standardized look for all patient rooms
  • Have no history of adverse events associated with exposed plumbing
  • Have clinical interventions in place to prevent patient self harm even with pipes present
  • Could have designated high risk rooms that don't have exposed plumbing
  • As treatment progresses, patient could move from a high risk from to a low risk room.

Step 3: Arguments supporting "no"

  • Exposed plumbing presents opportunities for patient self harm.
  • What if a clinical intervention fails? How do we prevent patient harm then?

 Step 4: Evaluation

  • Include all stakeholders: unit physicians, nursing staff, risk management, facilities, and administration representatives.

 Step 5: Conclusion

  • Decide whether to allow exposed pipes in BH units.

 Step 6: Documentation

  • Update relevant policies with information based on the decision.
  • Share the decision with the Safety Committee.

 Step 7: Monitoring and reassessment

  • Revisit the topic in three months.
  • If decision is valid, revisit annually.

 This 7 step model of risk assessment is relatively straightforward and easy to use. To ensure that your risk assessment is as robust as possible, we recommend the following additional strategies:

  • When evaluating the specific risk, be sure to bring data to the table. Review your incident database, client satisfaction data and complaints. Summarize the relevant data and present it to the group for their review and analysis.
  • Conduct a literature review to identify current professional thinking and best practices related to the topic.
  • Research the regulations. Clarify the TJC, CMS and state licensing requirements related to the issue.
  • Once you have reached a decision, clearly state your "organizational position" and include a full rationale for how you decided upon this position.
  • Write up the risk assessment as a formal report. You can use the 7 step model as your outline.
  • Have the formal risk assessment report reviewed by the appropriate committees and attach it to their minutes. Once these bodies have reviewed the risk assessment and approved the organizational position, include this approval in the final risk assessment report itself (see example below).



Date of Review & Approval

EOC Committee

January 5, 2013

PI Committee

February 10, 2013

Executive Council

March 15, 2013


Keep in mind that the purpose of conducting a risk assessment is threefold:

  1. To determine the potential risks of an action or a situation
  2. To evaluate the extent of those risks
  3. To decide whether to accept, mitigate, or avoid those risks.  

In order to do this effectively, the organization should have an established process for conducting risk assessments. The 7 step model is an example of such a process. Consider using it in your organization as another one of your PI tools. To read the full article, click on March 2013 Perspectives and see page 5 "Risk Assessment Process: A Seven-Step Approach".

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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.