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Joint Commission Behavioral Health Update

 February 2014      
In This Issue
Congratulations Corner
New Client Welcome!
Proposed Revisions to Behavioral Health Human Resources Chapter
Proposed Clarification: Current TJC Requirements for FMEAs
Sign Up for Our 2014 TJC Update Sessions
Barrins & Associates
Barrins & Associates
Greetings to Our Colleagues in Anne Barrins
Behavioral Healthcare!  


We hope that you are surviving winter in your part of the country and send a special "shout out" to our hearty colleagues in the Northeast! This month, we have several updates for you on TJC related topics:


Our first article reviews the proposed revisions to the Human Resources chapter in the Behavioral Health Care Accreditation Manual. Our second article provides clarification on the TJC requirements for conducting a Failure Mode and Effects Analysis (FMEA). Our third article provides information on our annual TJC Update Long Distance Education Sessions designed to bring you the latest information on TJC requirements, standards changes, and top focus areas for 2014.


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 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.

FMEAS - left side

 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."  

   Sign Up for Our 2014 TJC Update Sessions

With the New Year underway, the 2014 TJC standards are now in full effect. As part of your continuous readiness program, it's critical for you and your team to be up to speed on the current TJC requirements, recent changes, and top focus areas.


To support your efforts, we are again offering our popular TJC Update Long Distance Education Sessions. Many clients and newsletter readers have taken advantage of these sessions as an efficient, cost effective way to focus their teams on TJC's top priorities for the New Year.


When we conduct the session with your team, we help you figure out how best to apply the current requirements in your particular setting. We also provide insights from our clients' 2013 surveys that can help you be ready for your next TJC survey.


For more information on how to arrange a TJC Update Long Distance Education Session, click on the links below:


 We look forward to talking directly with you about how the 2014 requirements impact your organization!

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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.