Joint Commission Behavioral Health Update
July 2016
In This Issue:

Greetings to Our Colleagues in Behavioral Healthcare!
Now that summer has reached its peak, we trust that many of you are taking some well-deserved vacation. To keep you informed even in this more leisurely season, we are providing information this month on two topics of interest.
Our first article provides feedback and highlights from our clients who have been surveyed since TJC implemented changes to the survey process and scoring methodology for psychiatric hospitals. Take note because it's important information for your next survey. Our second article discusses the proposed changes to the Behavioral Health standard related to outcomes measurement. Read carefully as it has significant implications for any accredited behavioral health organization. 

We value your feedback on the newsletter. Please send 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 to your colleagues.

Enjoy the rest of your summer and we will be back in touch in September!

Anne Barrins
Prepared for Your Next TJC Deemed Status Survey?
Does your psychiatric hospital use TJC for deemed status? If so, prepare for a strong CMS focus on your next survey. Contact us now to schedule a mock survey that covers both TJC and CMS requirements including the most currently challenging standards.
Tip of the Month
If you are storing oxygen tanks in your setting, check out the recent FAQ on the TJC website Oxygen Cylinder - Storage Management. We have seen several recent RFIs on this topic and the FAQ is a good guide to best practice in this area.
Why Choose
Barrins & Associates?

"The most helpful aspect of our Barrins & Associates consultation was the education and on-the-spot technical assistance we received from our consultants Colleen Sawyer and Claire Burchfield. Their mock survey was the best practice we could possibly have for our actual TJC survey. It kept us abreast of the current high focus areas which was of great value to us."

Garry Hoyes, CEO
Dublin Springs Hospital
Dublin, Ohio
If you are a psychiatric hospital using TJC accreditation for deemed status, you know that TJC recently implemented some significant changes to its survey process and scoring methodology.  These include closer scrutiny of the two Special Conditions of Participation for psychiatric hospitals (B Tags) and use of the SAFER (Survey Analysis for Evaluating Risk) matrix for survey reports. The SAFER matrix summarizes survey findings based on the estimated level of risk to patients, staff, and visitors.
BH Outcome Measures
Proposed Standards Revision
TJC has published proposed standards revisions for the Behavioral Health Accreditation Program related to outcomes measurement. Currently, there is one standard in the Behavioral Health manual related to outcomes. That standard is CTS.03.01.09 which requires BH organizations to assess the outcomes of care, treatment, or services provided to clients. It requires that organizations monitor the progress of individuals served in achieving their identified goals. It also requires that the organization aggregate outcomes data and evaluate outcomes across the population served.
Barrins & Associates is pleased to welcome three new clients:
Fairfax Hospital in Kirkland, Washington, Sober College in Los Angeles, California, and Arbour Health System in Massachusetts. We are pleased to be working with these organizations on regulatory and accreditation compliance. 
Congratulations corner
Congratulations to our client Sobertec, who recently achieved initial Joint Commission accreditation! 
Barrins & Associates provides Joint Commission and CMS consulting services for the Behavioral Healthcare industry. Our clients include psychiatric hospitals and freestanding Behavioral Healthcare organizations. We specialize in providing Survey Preparation and Continuous Survey Readiness services for the Behavioral Healthcare industry. Barrins & Associates was founded by Anne Barrins who was a Joint Commission surveyor for 13 years.