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Joint Commission Behavioral Health Update

June 2013        
In This Issue
Congratulations Corner
BH Organizations: Additional Flu Vaccination Requirements Effective 7/1/13
Managing Contracted Clinical Services
Barrins & Associates
Barrins & Associates
Greetings to Our Colleagues in Anne Barrins
Behavioral Healthcare! 


Now that summer has come to all parts of the country, we trust that many of you are planning some well deserved vacation time. To support your survey readiness efforts even during this more leisurely season, we are providing information on two topics of interest.


Our first article provides information on the additional influenza vaccination program requirements that go into effect on 7/1/13 for organizations surveyed under the Behavioral Health standards. Our second article reviews the TJC requirements for contacted clinical services, a topic which continues to get close scrutiny on surveys.


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 


This month we are extending congratulations to two clients who recently achieved their initial Joint Commission accreditation:


Congratulations to Novus Medical Detox Center located in New Port Richey, Florida! Novus Medical Detox Center provides medically monitored drug detoxification services in a residential setting with an emphasis on individually tailored detox programs for each patient.


Congratulations to Monarch Cove Treatment Center located in Pacific Grove, California on the Monterey Peninsula!

Monarch Cove Treatment Center is a new, specialized residential treatment center for eating disorders. It provides both residential and day treatment services and is an affiliate of the Castlewood Treatment Center for Eating Disorders in St. Louis, Missouri.


Kudos to both of these organizations on achieving the gold standard of Joint Commission accreditation!

BH Organizations: Additional Flu Vaccination Requirements Effective 7/1/13


In 2012, new flu vaccination requirements were introduced to the Behavioral Health standards. The majority of those went into effect 7/1/12 and most organizations accredited under the BH standards have now implemented their flu vaccination programs.


However, be aware that three new requirements go into effect on 7/1/13. From that point onward, surveyors will evaluate your flu vaccination program to be sure it addresses the following additional requirements:


Element of Performance # 5: The organization sets incremental influenza vaccination goals, consistent with achieving the 90% rate established by the national influenza initiatives for 2020.

This means you must show documentation that you have set goals that will progressively move you toward achieving that 90% goal by 2020. During a training session, TJC showed the following example:


Meeting the intent: Organization A has a current flu vaccination rate of 50% and sets the following goals:

  • 2012: 60%
  • 2014: 75%
  • 2016: 85%

NOT meeting the intent: Organization B has a current flu vaccination rate of 50% and sets the following goals:

  • 2012: 52%
  • 2014: 54%
  • 2016: 55%

Element of Performance # 6: The organization has a written description of the methodology used to determine influenza vaccination rates.

This means you must describe in writing how you are calculating your flu vaccination compliance rate. This involves defining who is included in the numerator and who is included in the denominator. If you are looking for guidance on how best to do this, download the National Quality Forum Measure Submission and Evaluation Worksheet. The document is lengthy but page 1 provides basic information on a methodology for calculating vaccination compliance rates.


Element of Performance # 8: The organization improves its vaccination rates according to its established goals at least annually.

This means that, going forward, your organization must be able to demonstrate that it has made a concerted effort to improve flu vaccination rates according to its established goals. This should be approached within a performance improvement framework with data collection, data analysis and the full PDCA cycle.


As you are refining your flu vaccination program, keep in mind the following important points about TJC's requirements:

  • The organization is not required to pay for the flu vaccine.
  • Staff is not mandated to receive the flu vaccine. They can decline it.
  • Staff is not required to sign a flu vaccine declination form.
  • The flu vaccine should be offered to contracted staff. Their compliance rate should be tracked separately from organizational staff.

Several clients have asked how surveyors are reviewing the flu vaccination requirements during surveys. Typically, surveyors are scrutinizing the following issues:

  • Have you implemented a comprehensive, organization-wide flu vaccination program?
  • Is the flu vaccination program integrated with the infection control program?
  • Do you have data on your flu vaccination compliance rates?
  • Who is reviewing the data?
  • Are you finding ways to improve your compliance rates? What seems to be working the best?
  • Has the data been provided to leadership and how have they been involved in improving compliance rates?
  • What will you do differently next year to improve your compliance rate?

Click on the links below for additional resources on flu vaccination programs:

  Managing Contracted Clinical Services


During recent TJC surveys, we have continued to see substantial scrutiny of contracted services. To answer several questions raised on this topic, we are providing an update to information shard with our readers in a previous newsletter. The following outlines the TJC requirements that apply to contracted clinical services. These requirements are included in the Human Resources chapter and the Leadership chapter of both the Behavioral Health and Hospital manuals.


Human Resources Chapter Requirements


If your organization has contracted with an individual or an agency to provide clinical services to your patients/clients, you must have verified information of the following for the contracted personnel:

  • Education/training consistent with regulatory requirements and organization policy
  • Licensure, certification, registration (when applicable)
  • Evidence of competence as required by the contracting organization
  • Orientation to the contracting organization
  • Performance evaluation for the contracted personnel
  • Health status information as required by the contracting organization
  • Criminal background check as required by the contracting organization
  • References as required by the contracting organization 

Essentially, there are two different approaches you can take to ensure that you have this verified information:

  • You (the contracting organization) can maintain the information yourself and set up the equivalent of human resource files for the contracted personnel OR
  • You can include in the contract the requirement that the contracted agency maintain this information. 

If you use the latter approach and depend upon the contracted agency to maintain this information, TJC now requires that an audit be conducted either by you or by the contractor to verify that the required information is available. TJC has clarified that "the audit must include an attestation as to the accuracy of the information. A simple attestation letter indicating that the information is current and on file at the organization site without the audit is not sufficient." See the FAQs on this topic at Hospital FAQ and Behavioral Healthcare FAQ.


Leadership Chapter Requirements


There are also requirements in the Leadership chapter that apply to contracted clinical services. The relevant standard is LD.04.03.09 in both the Hospital and Behavioral Health manuals. The wording is slightly different in the two manuals but the content is the same. Standard LD.04.03.09 requires the following:

  • Clinical/medical leadership must have input to approving the providers for contracted clinical services.
  • Contracted clinical services must be described in writing. This can be through a contract, letter of agreement or memorandum of understanding.
  • Leadership must approve contractual agreements.
  • Leadership must define written performance expectations for the contracted service and communicate these to the contractor. For example:
    • Contract nutritionist: will conduct nutritional evaluations within 72 hours of referral and send a written report within one week of the evaluation.
    • Contract teachers: will attend weekly treatment team meetings and provide input to treatment team regarding adjustment to the school program
    • Contract nursing agency: will assign nursing staff within two hours of the hospital's request
    • Contract radiology service: all routine radiology reports within 24 hours; all STAT results within 90 minutes of order
  • Leaders must monitor contracted serves by evaluating them against the performance expectations defined in the contact. The ongoing evaluation of the service can be delegated to a manager or a committee within the organization but at least annually leadership must evaluate the contracted service and make a decision about continuing or discontinuing the contract.  

Survey Process


Be prepared for a discussion of clinical contracts during your survey. Have the following material available:

  • A list of all contracted clinical services
  • The actual contract (or letter of agreement) documents
  • Evidence in minutes that medical/clinical staff has had input to the contracts
  • Evidence that leadership has approved the contract
  • Written performance expectations in the contract
  • Evidence that contracted personnel have the appropriate credentials/qualifications
  • Evidence that contracted personnel have received an orientation to your organization
  • Annual review of the contractor's performance as per the performance expectations  

Survey Pitfalls


We have frequently seen things go awry during survey when the surveyor encounters a service provided by a contractor and asks for evidence of that individual's credentials. As described by one client who recently went through this experience: " We assumed  that the hospital was maintaining a copy of the certification for the phlebotomist that they send over here but when we contacted them to produce that documentation during the survey, we couldn't find anyone who knew where it was."

Heads Up: if you are relying on your contractor for this information, test it out prior to your survey to make sure it's easily retrievable.


The other common pitfall is showing evidence of orientation to your organization for contracted personnel. Remember, they need an orientation to your unit, program or service. It can be brief and tailored to their specific role on the unit but some type of basic orientation must occur and be documented. What often happens is that this orientation is done on a somewhat informal basis by the unit manager and is not documented.

Heads Up: Develop a brief orientation checklist that can be used with any contracted personnel. Include clinical documentation requirements, confidentiality, fire safety, infection control, etc.


Bottom Line: Don't forget contracted clinical services when preparing for you next survey! There are requirements in both the Human Resources and Leadership chapters that are important and may receive close scrutiny during survey.


Additional Note: If a Licensed Independent Practitioner (LIP) is providing the contracted clinical service on site at your organization, that LIP should go though one of the following processes:

For hospitals: the process for credentialing and privileging of LIPs outlined in the Medical Staff chapter

For Behavioral Health organizations: the process for credentialing and assignment of clinical responsibilities for LIPs outlined in the Human Resource chapter.

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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.