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Joint Commission Behavioral Health Update

 May 2014        
In This Issue
New Client Welcome!
Congratulations Corner
"High Reliability": Important Topic for TJC Leadership Interview
Competence Assessment in Behavioral Health
Barrins & Associates
Barrins & Associates
Greetings to Our Colleagues in Anne Barrins
Behavioral Healthcare!  


We hope that spring has reached your region of the country and that the sunny days of summer are not far behind!


This month, our first article provides information on an important topic finding its way into the Leadership interview on TJC surveys: high reliability in healthcare organizations. Our second article answers some frequently asked questions on competence assessment which continues to be a challenging area for many Behavioral Health organizations.


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 Black Bear Lodge located in the foothills of northern Georgia. Black Bear Lodge offers a holistic model of integrated substance abuse and mental health treatment and is working toward initial Joint Commission accreditation. The program is part of Foundations Recovery Network with headquarters in Nashville, Tennessee 

 Congratulations Corner      


Congratulations to our client Bayes Achievement Center located in Huntsville, Texas who recently underwent their highly successful initial survey from The Joint Commission! Bayes Achievement Center provides a full continuum of prevention services, residential treatment and a day school program for special needs students with significant behavioral difficulties. Congratulations to the Bayes team on their diligent preparation and their highly successful outcome on their initial TJC survey!

"High Reliability": Important Topic for TJC Leadership Interview 


For several years, the common topic for the leadership interview on the last day of the survey was the five "pillars of leadership" as described in standards LD.03.01.01 - LD.03.06.01:

  • Using data
  • Planning
  • Communicating
  • Changing Performance
  • Staffing

This topic is still often used during leadership interviews on Behavioral Health surveys. Thus, BH leaders should be prepared to discuss how they are using these functions to drive safety and quality within their organizations.


More recently, however, during surveys of psychiatric hospitals (as in surveys of all types of hospitals) the surveyors are focusing on the topic of high reliability in healthcare.  High reliability in healthcare seeks to apply lessons learned from industries such as commercial aviation and nuclear power that operate under hazardous conditions yet maintain safety levels much higher than healthcare. Proponents advocate that adapting lessons of high reliability science to healthcare offers the promise of enabling hospitals to reach levels of quality and safety comparable to those of the best high reliability organizations.


A key article on this topic is "High-Reliability Health Care: Getting There from Here" by Mark Chassin, MD, TJC President/CEO and Jerod Loeb, Ph.D., TJC Executive VP for Healthcare Quality Evaluation (2013.)  It describes the concept of high reliability and adapting this science to hospitals. The article also offers a framework for assessing your hospital's journey toward high reliability. There is a grid on which you can rate your hospital's stage of maturity in three critical domains:

  • Leadership
  • Safety Culture
  • Performance Improvement

In each of these domains, the model describes characteristics of hospitals that are in the following developmental stages:

  • Beginning
  • Developing
  • Advancing
  • Approaching

Thus, if you are preparing for an upcoming TJC survey, you will want to familiarize yourself with the concept of high reliability in healthcare and share this article with your leadership team. Even if you are not preparing for survey, the concept is great food for thought for any leadership team building a culture of safety and quality within their organization. There are additional resources on this topic on the TJC website. Visit the High Reliability Resource Center to view articles, publications and videos and to learn about how other hospitals are applying high reliability within their organizations.

Competence Assessment in Behavioral Health 


During surveys of both psychiatric hospitals and behavioral health organizations, issues continue to arise around how the organization is assessing the competence of its clinical staff. We have seen several survey findings for organizations not clearly defining competencies and not having a process for ongoing evaluation of clinical competencies. So, in this article, we are answering some questions we've received about competence and providing examples of methods for competence assessment. 


What does the term "competence" mean?


Competence has two components. The first component is knowledge and the second component is skill. The difference between the two is that knowledge is the preparation for performance and skill is the demonstration of performance. Knowledge is assumed to exist based on credentials such as academic degrees, licensure/certification, etc. However, skill can only be confirmed by direct observation of an individual's performance or review of the outcomes of that performance. The key point here is that knowledge does not necessarily result in skill whereas skill is evidence of knowledge.


What kinds of skills are considered competencies?


Competence involves three types of skills: cognitive skills, psychomotor skills, and interpersonal skills:


Cognitive skills (critical thinking skills) include the following:

  • Ability to analyze and see the importance of observations and events
  • Ability to analyze a situation and anticipate future events
  • Ability to be proactive rather than reactive

An example in a BH setting would be the counselor's ability to interpret that the client's withdrawal from program activities signals decompensation.


Psychomotor skills include the ability to perform physical tasks learned from didactic training. Examples would be CPR, AIMS testing, restraint, and physical holds.


Interpersonal skills include the ability to work with others. Examples would be interviewing clients and families, conducting group therapy, working with the treatment team, and engaging families in treatment.


Where should competencies be defined?


Clinical competencies must be delineated and put in writing. They can either be incorporated into the job description or they can be listed in a competency checklist that is separate from the job description. Many organizations find that the most efficient approach is to include the competencies in the job description. Other organizations have generic job descriptions that cannot be modified and so they develop separate competency checklists.


What are some examples of competencies for different types of BH practitioners?


Sample competencies for a primary therapist at a residential treatment facility:

  • Establish and maintain a therapeutic relationship with the client's support system (biological family/foster family/significant others)
  • Maintain professional relationships with referral agencies
  • Advocate for resident's needs to maximize resident's daily functioning

Sample competencies for an outpatient therapist:

  • Uses active listening skills that are sensitive to individual and cultural communication differences
  • Considers special needs (substance abuse, medical, housing) and incorporates them into the treatment planning process
  • Discusses treatment plans with clients in a clear and understandable manner

Once the competencies have been defined, the next step is to develop performance standards for these competencies. These performance standards will articulate the specific skills that the individual should be able to demonstrate in order to show their competence. Examples of performance standards for the competency "uses active listening skills" could include the following:

  • Seeks clarification of information from clients, families, co-workers
  • Paraphrases his/her understanding of the issue
  • Demonstrates sensitivity to cultural or disability differences

Examples of performance standards for the competency "considers special needs (substance abuse, medical, housing)" could include the following:

  • Can describe how they address special needs in the assessment and treatment planning process
  • Assessments and treatment plans reflect consideration of special needs


Once the competencies have been defined, how should the competencies be assessed?


Once the competencies have been defined, the organization needs to determine the methods it will use to assess competence. This includes defining how the skill will be evaluated; by whom; and at what intervals. Some of the common methods used to assess competence include the following:

  • Clinical supervision
  • Record review
  • Peer review
  • Observations
  • Case presentations
  • Self assessment

These competence assessment activities should be documented and the results then fed into the annual performance evaluation or competency checklist review. Keep in mind that the breakdown on surveys often occurs when the surveyor is reviewing one of those annual competency checklists but there is nothing to "back up" the check marks in the boxes. 


In response to a TJC survey finding in this area, one of our psychiatric hospital clients developed a competency assessment tool for their therapists. They kindly agreed to share this Therapist Competency Verification tool with our readers.  It can be modified or adapted to suit your setting and services.

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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.