Joint Commission Behavioral Health Update

Congratulations to our client La Paloma Treatment Center in Memphis, Tennessee who recently underwent their highly successful initial survey from The Joint Commission! La Paloma provides a full continuum of substance abuse treatment services including residential, PHP and aftercare services. They specialize in providing dual diagnosis treatment for individuals dealing with both substance abuse and mental health issues. Congratulations to La Paloma Treatment Center on achieving the gold standard of Joint  Commission accreditation!

 New Client Welcome!     

Barrins & Associates is pleased to welcome our new client SafetyNet Behavioral Healthcare located in Montgomery, Alabama. SafetyNet is a residential program that offers long term treatment for youth ages 10 to 18 with ongoing behavioral, emotional and/or psychiatric needs. The organization offers four distinct treatment programs on three separate campuses. SafetyNet Behavioral Healthcare is planning for initial Joint Commission accreditation and we are pleased to be working with them on that effort.

Proposed Revisions to Behavioral Health Human Resources Chapter 

TJC has proposed revisions to the Human Resources chapter in the Behavioral Health Care Accreditation Manual. The proposed revised standards are available on the TJC website on the Standards Field Review page.

The Field Review page contains both the proposed new standards/elements of performance and a crosswalk of the current standards to the proposed revisions.

The proposed revisions are an attempt to streamline and simplify the HR requirements pertaining to both staff and the category of practitioners that has been referred to as Licensed Independent Practitioners (LIPs). In the current HR standards, the requirements for LIPs are separate and more detailed than those for staff. These requirements for LIPs had been modeled after similar requirements for LIPs that are contained in the Medical Staff chapter of the Hospital Accreditation Manual. In the proposed standards, most of the requirements for LIPs are not defined separately than those for staff. Rather, the majority of requirements for both groups are addressed jointly in each of the standards.

Some of the highlights in the proposed revisions include the following:

• Greater clarity on job descriptions and what they need to include
• Allowing (in some instances) the use of primary source verification that has been completed by another Joint Commission accredited organization
• Simplification of the concept of granting clinical responsibilities to LIPs

As an accredited organization that will be affected by these proposed changes, it's important to provide feedback to TJC. Also, be aware that survey findings in the Human Resources chapter are very common on Behavioral Health surveys. So, we urge you to take the time to read the proposed changes and give TJC your feedback. The field review of the proposed standards ends on March 13, 2014.

 Clarification: Current TJC Requirements for FMEAs 

For several years, there was a requirement in the TJC standards for organizations to conduct an annual proactive risk assessment referred to as a Failure Mode and Effects Analysis (FMEA). The requirements for proactive risk assessment have evolved over the past few years and we frequently get questions about whether a FMEA is still required. So, here is a summary of the current TJC requirements:

For Hospitals Accredited under the Hospital Accreditation Standards:

In the Leadership chapter, standard LD.04.04.05 EP 10 states: "At least every 18 months, the hospital selects one high-risk process and conducts a proactive risk assessment." The standard then refers the reader to the section at the beginning of the Leadership chapter titled "Proactive Risk Assessment." This section uses the FMEA model as one method for conducting a proactive risk assessment.

So, the bottom line for hospitals is that they must conduct some type of proactive risk assessment every 18 months.

For Organizations Accredited under the Behavioral Health Care Standards:

There is the same section at the beginning of the Leadership chapter titled "Proactive Risk Assessment." However, under standard LD.04.04.05, there is no EP 10 requiring a FMEA every 18 months (as in the Hospital manual). Instead, EP 11 addresses the topic in the following manner: "To improve safety, the organization analyzes and uses information about system or process failures and, when conducted, the results of proactive risk assessments."

So, the bottom line for BH organizations is that conducting a FMEA is not a requirement per se. It is one of the methods that an organization can use to analyze system or process failures.

Also, it's important to keep in mind that if your organization does conduct a FMEA, it's critical that you focus not only on identifying the failure modes but also on implementing a redesign that shows a measurable improvement to the process. It's best to narrow your redesign actions to a critical few and actually measure the success of each one. As noted by Erik Stalhandske, MPD, MHSA of the VA National Center for Patient Safety: "It's better to have fewer (redesign) actions that actually get implemented than a myriad of half-addressed or ignored actions."