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Joint Commission Behavioral Health Update

 April 2014        
In This Issue
New Client Welcome!
Suicide Risk Assessment: Patient Bathrooms
Medication Instructions at Discharge
No More Complimentary Standards Manuals
Barrins & Associates
Barrins & Associates
Greetings to Our Colleagues in Anne Barrins
Behavioral Healthcare!  


This month marks a milestone for the Barrins & Associates newsletter. We distributed the first issue in April 2009. So, this month we are marking our five year anniversary! We have found the newsletter to be a great vehicle for staying in touch with our clients and colleagues. It's gratifying when we get feedback about how helpful the newsletter is to folks out there in the field. So, keep your questions and comments coming and we'll continue to bring you information and resources that support your survey readiness efforts! Also, back issues of the newsletter are available in the Newsletter Archive on our website.


This month, our first article offers a resource on conducting risk assessments on patient bathrooms, a topic that has come up frequently during surveys. Our second article conveys information about how surveyors are reviewing discharge instructions related to medications. Lastly, we have a reminder about TJC's discontinuation of distributing hard copies of standards manuals 


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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 New Client Welcome!    


Barrins & Associates is pleased to welcome our new client Haven Behavioral Hospital of Philadelphia which offers specialized inpatient psychiatric treatment for older adults. The hospital is part of Haven Behavioral Healthcare Inc. which specializes in the treatment of seniors experiencing psychiatric or behavioral problems. Haven BH Hospital of Philadelphia recently achieved the gold standard of TJC accreditation and we are pleased to have assisted them in achieving that goal.

Suicide Risk Assessment: Patient Bathrooms 


During surveys of inpatient psychiatric units (and sometimes in residential programs) TJC surveyors continue to cite suicide risks they identify in the environment. Commonly occurring issues are plastic trash can liners, loopable hardware in bedrooms and bathrooms, and non-breakaway fixtures 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 and then analyzed the results to make an informed decision about how to address the identified risk. 


One of the most high risk locations for suicide attempts is patient bathrooms. In psychiatric hospitals, the most frequent method of suicide is hanging. It is estimated that 75% of inpatient suicides occur in the patient's bathroom, bedroom, or closet. Many psychiatric units have already taken steps to eliminate hanging and self-harm risks in patient bathrooms. Others have made the decision not to eliminate these risks because they feel that they have sufficient mitigating features in place.


If you are in the process of assessing risks in patient bathrooms in your setting, you may find the Suicide Risk Assessment Tool for Inpatient Bathrooms useful. It provides a format for determining if key best practice environmental features are in place to help minimize the risk of suicide in the bathroom. A critical component of the tool is that once a risk is identified and rated, there is an outline for documenting your evaluation of that risk, your conclusions, and your course of action.


For additional information on the topic of risk assessment, see our May 2013 newsletter article Conducting and Documenting Risk Assessments. Another useful tool for conducting a unit-wide risk assessment is the ECRI Institute Healthcare Risk Control Self Assessment Questionnaire.

Medication Instructions at Discharge 


The TJC focus on the discharge process continues in 2014. During surveys, surveyors will frequently request a sample of closed records. In the past, the focus for closed records was on determining if the discharge summary had been completed on time. More recently, however, surveyor focus has been on evaluating whether the patient/client was given appropriate instructions about their medications at discharge. Two issues are getting close scrutiny:


Issue #1: Were the medication instructions provided to the client/family in a way that they could easily understand?

There is a standard in both the Hospital and Behavioral Health manuals that speaks directly to this issue:


Hospital Manual: PC.04.01.05 EP 8:"The hospital provides written discharge instructions in a manner that the paaptienand/or the patient's family or caregiver can understand."

BH Manual:CTS.06.02.03 EP 9:"The organization provides the individual served and his/her family, if applicable, discharge instructions in a form the individual can understand. 


Several organizations have been cited for the fact that their discharge instructions related to medication were written in medical terminology that could not be easily understood by the client/family. Surveyors have specifically cited terms such as "BID, QHS, PO and QAM" as not being in consumer friendly language. Thus, it's important to ensure that whoever is preparing the discharge instructions writes the medication instructions in "everyday" language such as "twice a day," "by mouth," etc.


Issue # 2: Was the client educated about the medications he/she should be taking after discharge?

The Medication Reconciliation standard addresses the requirement for educating the patient/client about their medications at discharge:


Hospital Manual: NPSG.03.06.01 EP 5: "Explain the importance of managing medication information to the patient when he or she is discharged from the hospital or at the end of an outpatient encounter."

BH Manual:NPSG.03.06.01 EP 5: "Explain the importance of managing medication information to the individual served."


Several organizations have been cited for not educating patients/clients about their medications at discharge. The typical scenario is that the surveyor reviews a copy of the discharge instructions and there is no documentation (either on the discharge instruction form or in a progress note) that the patient received education about their medications at discharge. So, we recommend that you build into your discharge instructions form a place to document the medication education that was provided. This can be as simple as a check-off box that indicates the education was provided. For more information on how surveyors are evaluating the discharge process, see our March 2012 article Increased Focus on Discharge Planning in Psychiatric Hospital Surveys.

No More Complimentary Standards Manuals 


Be aware that effective January 2014 TJC will no longer be mailing complimentary hard copies of the standards manuals and standards updates to accredited organizations. Standards manuals and standards updates will be available to accredited organizations via E-dition (the electronic version of the standards) on their Joint Commission Connect extranet site. (See December 2013 TJC Perspectives page 4.)

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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.