Barrins & Associates Newsletter Banner

Joint Commission Behavioral Health Update

November 2014     
In This Issue
New Client Welcome!
Congratulations Corner
National Patient Safety Goal on Alarm Management: Relevance for Psychiatric Hospitals
Q&A on Behavioral Health Human Resource Standards and Requirements
Barrins & Associates
Barrins & Associates
Greetings to Our Colleagues in Anne Final for Newletter
Behavioral Healthcare!

Thanksgiving greetings to our clients and colleagues across the country! Before the hectic holiday season ensues, we have a few TJC updates for you.


Our first article deals with the National Patient Safety Goal on clinical alarms. This is an important patient safety issue and a relevant topic for our psychiatric hospital clients.


Our second article responds to some recently received questions from behavioral health organizations related to the Human Resources chapter in the BH manual.


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. 


Best regards for a Happy Holiday Season and our newsletter will return in January 2015.


Newsletter Signup

Welcome - Left  New Client Welcome!        


Barrins & Associates is pleased to welcome two new clients this month:

Elmhurst Professionals Program is located near Chicago in Elmhurst, Illinois and is a member of the Achieve Network. The program offers holistic recovery treatment with a specialty in treating professionals. Elmhurst Professionals Program is planning to pursue TJC accreditation and we are pleased to be working with the Elmhurst team to achieve that goal!

Westpark Springs is a newly constructed, state-of-the-art 72 bed behavioral hospital located near Houston in Richmond, Texas. The hospital opened in October 2014 and provides inpatient and outpatient mental health and addiction treatment to adults and their families. Westpark Springs is part of Springstone Inc. with headquarters in Louisville, Kentucky. Westpark Springs is preparing for initial Joint Commission accreditation and we are pleased to support them in achieving that goal!

 Congratulations Corner    


Congratulations to our client WestCoast Children's Clinic in Oakland, California who recently achieved initial Joint Commission accreditation! WestCoast Children's Clinic provides clinic based, school based and home based therapy services to children and families. Congratulations to the WestCoast team on achieving the gold standard of Joint Commission accreditation!

National Patient Safety Goal on Alarm Management: Relevance for Psychiatric Hospitals 


In January 2014, TJC introduced the National Patient Safety Goal on Alarm Management (NPSG.06.01.01) for hospitals and critical access hospitals. Since psychiatric hospitals are surveyed under the Hospital standards, this National Patient Safety Goal is applicable in those settings. Thus, many psychiatric hospitals have been grappling with how best to comply with this new requirement. So, let's take a look at just what TJC requires and how best to apply that in the psychiatric hospital setting.


The focus of this National Patient Safety Goal is on clinical alarms. TJC defines a clinical alarm as "A component of some medical devices that is designed to notify caregivers of an important change in a patient's physiologic status. A clinical alarm typically provides audible and/or visible notification of the changed patient status."


The impetus for this National Patient Safety Goal comes from the acute care hospital setting where it has been shown that a myriad of alarms can result in "alarm fatigue" and staff failing to respond to alarms with resulting fatal consequences for patients.


Psychiatric hospitals typically do not have the abundance and variety of clinical alarms that acute care hospitals have. However, there are some types of alarms that are used in psychiatric hospitals that do fit into this category such as bed and chair alarms for geriatric patients and doorway movement alarms sometimes used on adolescent units.


In addition, it's important to approach this National Patient Safety Goal from the perspective of complying with the spirit of the requirement and not just the "letter of the law." For example, while the alarm on the door of an inpatient psychiatric unit may not meet the strict definition of a clinical alarm, it's critical to know that this alarm is operating properly, has been correctly set, and staff know how to respond to it. (As a case in point, we were part of a root cause analysis two years ago in which a patient escaped from an inpatient unit and died in a traffic accident after a staff member had disabled the alarm because it was malfunctioning.)


So, we have been advising our clients to take the following steps related to this National Patient Safety Goal:

  • Develop an inventory of the alarms in your setting that are designed to alert you to a patient's status or patient activity that should prompt a staff response

  • Identify in writing the inspection and maintenance procedures for these alarms.

  • Identify in writing the processes in place for monitoring the operation of these alarms.

  • Define staff training requirements related to these alarms and how ongoing competency will be assessed.

Also, be aware that this National Patient Safety Goal requires that effective July 1, 2014 "Leaders establish alarm system safety as a hospital priority." The best way to do that is to educate your leadership team and medical staff on the background and requirements of this National Patient Safety Goal. Review with them your alarm inventory, inspection/maintenance procedures, monitoring processes and staff training (as outlined above) and get their input on how to make this a top safety priority within your hospital. Document these discussions, plans and actions in your minutes so that you can readily demonstrate to surveyors that you have indeed established alarm safety as a hospital priority.


For additional information on alarm safety, check out the following resources:  

ECRI Institute Alarm Safety Resource Site

TJC Sentinel Event Alert: Medical Device Alarm Safety in Hospitals

Q&A on Behavioral Health Human Resource Standards

and Requirements 


As reported in our October newsletter, there are revisions to the standards in the Behavioral Health Human Resources chapter (effective January 2015) that will make the process for "credentialing and privileging" of licensed independent practitioners simpler. As our clients have been reviewing these revisions, we've received some questions about both old and new requirements in the Human Resources chapter that we thought might be useful to clarify:

How often does primary source verification need to be done?

Primary source verification of licensure, certification, or registration must be done both at time of initial hire and when this credential is renewed. (The problem that we have seen organizations sometime have on survey is a lapse in verifying the renewal of the credential so be sure to have a solid "tickler" system for doing this.)

Can primary source verification of licensure suffice for primary source verification of education/training for licensed independent practitioners?

Yes, primary source verification of licensure can satisfy the requirement for primary source verification of education/training IF you have confirmed with the state licensing board (for that profession) that they verify the individual's education and training prior to granting the license.

TJC requires that clinical competency be assessed by an individual who has similar training and experience. We have only one dietician in our organization so who can assess her competence?

In situations such as this when there is no other "like practitioner" in the organization, input on competence can be obtained from a like practitioner outside of the organization. For example, this input could be from a dietician at another agency where your dietician works. If this is not possible, a process could be set up whereby you arrange for an outside dietician to conduct peer review on your dietician. Also, keep in mind that the administrative portion of this individual's performance evaluation does not need to be done by a clinical peer. It is only the clinical competence assessment that requires peer input.

TJC requires an initial assessment of staff competence as part of orientation. What are they looking for?

This requirement (HR.01.06.01 EP 5) is focused on making sure that you not only orient staff to their job responsibilities but also assess their competence (during the orientation period) to carry out those job responsibilities. For most organizations, there are a couple of key components of orientation that they can show to demonstrate that they have done this competence assessment:

  • Tests, quizzes, and/or return demonstrations that staff are required to complete for the different modules of orientation

  • Documentation of mentoring during the orientation period

  • Initial/probationary performance evaluations completed at the end of the orientation period: If your organization conducts some type of initial or probationary performance evaluation (for example at three months after hire,) this is also evidence of an initial assessment of competence during the orientation period. (Note: If it is your policy to conduct this type of probationary performance evaluation and the surveyor finds that this has not been done, you will be out of compliance.)

Do contracted staff need to have the same orientation as employees?

Similar to employees, contracted staff need to have some type of orientation but it does not need to be as extensive as that done for employees. Orientation for contractors can be an abbreviated one that addresses key topics such as client safety, confidentiality, documentation requirements, etc.

Do we now need to review driver's licenses for all staff to verify their identity?

Effective January 1, 2015, it is required that you view a valid picture ID issued by a state or federal agency (e.g. driver's license or passport) to verify the identity of the individual. Previously, this was required only for licensed indecent practitioners.

We have a process in place for credentialing and privileging our physicians according to the current HR standards and this is working for us. Do we need to change anything based on the new 2015 standards?


No. If your process is working for you, you can continue using it. The changes to the standards that help simplify this process provide an option for organizations that found the previous process too cumbersome.

B&A Logo 
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.