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Joint Commission Behavioral Health Update

 March 2014       
In This Issue
Congratulations Corner
New Client Welcome!
Competence Assessment by a Qualified Individual
Barrins & Associates Attends TJC Consultants Forum
Sign Up for Our 2014 TJC Update Sessions
Barrins & Associates
Barrins & Associates
Greetings to Our Colleagues in Anne Barrins
Behavioral Healthcare!  


We hope that spring is beginning to reach most of you out there across the country! We survived our winter travel schedule and for that I thank my steadfast associates and flexible clients!


This month, we have updates for you on several TJC related topics. Our first article provides some advice on competency assessment for "specialty practitioners." Our second article relays information from the TJC Consultants Forum that we recently attended at TJC headquarters. 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 Fred Finch Youth Center headquartered in Oakland, California who recently achieved their initial Joint Commission accreditation! Fred Finch Youth Center offers an extensive range of mental health and social services to children, adolescents and families in the San Francisco Bay area and also in San Diego. Congratulations to Fred Finch Youth Center on achieving the gold standard of Joint Commission accreditation!

 New Client Welcome!    


Barrins & Associates welcomes two new clients this month:


Tranquil Shores in Madeira Beach, Florida specializes in an Integrative Recovery Model to treat alcohol and substance abuse. Services include outpatient substance abuse treatment and transitional housing with a focus on long term recovery. Tranquil Shoresis planning for initial Joint Commission accreditation and we are pleased to be working with them on that effort.


Bienvenidos Children's Center  is headquartered in Los Angeles, California. Bienvenidos provides a wide range of mental health, community services, foster care and medical services to children and families at 11 locations in the greater Los Angeles area. Bienvenidos is planning for initial Joint Commission accreditation and we are pleased to be working with them on that effort.

Competence Assessment by a Qualified Individual 


There is a standard tucked into the TJC Human Resources chapter that seems innocuous at first reading but frequently causes challenges on surveys. The standard is HR.01.06.01 Element of Performance # 3 in both the Behavioral Health and Hospital manuals:

"Staff with the educational background, experience, or knowledge related to the skills being reviewed assess competence."


Here's how this standard is typically reviewed by surveyors: During the Human Resources interview, they will ask for the file of a specialty or "one of a kind" practitioner such as an occupational therapist, a dietician, or a rehab therapist. Then, the surveyor will review the HR file to see if that practitioner has had input to their clinical competence assessment from someone in the same discipline. The concept is that the individual conducting the competency assessment must have the appropriate background and training to assess the clinical competence of the practitioner being evaluated.


 So, where do problems arise? The following are examples from actual surveys:

  • The organization had only one dietician and her performance evaluation had been conducted by an administrator with no input from another dietician.
  • The nurses who worked in a community based program had been evaluated by the program director who was not a nurse.
  • The contract occupational therapist had never had any type of competence assessment.
  • The activity therapists were being reviewed by the Director of Nursing.

Thus, it's important to have a mechanism in place to ensure that these types of practitioners get input from a peer in the same discipline. What are the options? First, identify if there is a clinical peer within your own organization. This can either be someone in a supervisory position or a colleague working in the same position. If there is no clinical peer within your organization, is there a "sister facility" within your system that has the same type of practitioner who can provide a peer review? If neither of these is an option, TJC allows for obtaining a peer recommendation from an individual outside of the organization; for example, from a peer at another agency where the practitioner works.


What about the scenario in which there is no peer within the organization and the practitioner does not work at another agency where they can get a peer recommendation? In this case, the best approach is to retain (i.e. pay for) a peer from outside the organization to conduct some type of clinical review on your practitioner.


A few points of clarification on this issue:


  • The individual who is the administrative supervisor for the practitioner should complete the non-clinically related portions of the practitioner's performance evaluation. Input from a clinical peer is only required for the clinical responsibilities. 
  • The peer input should include some type of hands-on review of the practitioner's work: e.g. evaluation of clinical documentation; observation of work; case presentations, etc. This is, of course, easier to structure if the peer is within your organization because you can define the process and the format for documenting the peer review. However, if peer input is being obtained from a practitioner at another agency, you do not have as much control over the process. In this case, the peer review actually becomes more of a peer recommendation. However, this recommendation can still be structured (by you) such that you ask the peer reviewer to comment on specific aspects of the practitioner's work including the quality of their assessments and their plans of care. (See the sample at the end of this article for some generic peer review indicators that can be adapted to your setting and services.) 
  • The working definition of a peer that we have seen accepted by TJC is the following:
    • The peer is a practitioner in the same discipline; e.g. nurse to nurse. OR 
    • The two practitioners are peers because they are both working under the same job description. For example, the Outpatient Therapist job description allows for the position to be filled by a social worker, a licensed mental health counselor, or a marriage and family therapist. In this case, these individuals are considered peers.


Clinical Responsibilities





Assessments are thorough in evaluating clients' needs and making recommendations for treatment.





Diagnostic and therapeutic decisions are made based on client/ family information and preferences, scientific evidence, and clinical judgment.





Documentation is completed within the required timeframes.





Documentation reflects the standards for quality established by the organization.





Practitioner collaborates with other members of the clinical team for coordination and management of ongoing care.





Practitioner fulfills assigned clinical responsibilities, (i.e. is reliable and available).






Barrins & Associates Attends TJC Consultants Forum 


I was pleased to represent Barrins & Associates at The Joint Commission's first forum for consultants who work with healthcare organizations. The Consultants Forum was held on February 13th at TJC headquarters in Oakbrook Terrace, Illinois.


The focus of the forum was to discuss issues of mutual interest to consultants, TJC and accredited organizations. Presentations were made by Dr. Mark Chassin, President and senior TJC staff including COO Mark Pelletier, RN, MS. There were also breakout sessions designed to elicit feedback from the consultants on the following topics:

  • Non-Value Activities of the Survey Process
  • Post- Survey Process: how it can be improved
  • Non-Value Added Standards
  • Changing the "C-Suite" Perceptions of TJC 

The meeting was very informative and collegial. TJC representatives were extremely open to feedback on how the accreditation and survey process can be more value-added for its customers. I was pleased to represent Barrins & Associates at this event and look forward to continued collaboration with TJC on this topic.

   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.