We hope you find the following resources helpful for your ongoing compliance with TJC and CMS requirements. We have included articles from the current issue of our newsletter as well as access to our newsletter archives and useful Industry Links for Behavioral Healthcare.

To read articles written prior to January 2015, please view our Newsletter Archive.

 

As reported in our March newsletter, significant changes are occurring to the TJC accreditation process for psychiatric hospitals. TJC recently sent an email to all psychiatric hospitals that use accreditation for deemed status. It outlined the changes to survey reports, scoring, and the post-survey response process effective June 6, 2016. In addition, there have been some changes to the TJC survey process for psychiatric hospitals.
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During some recent consultations, we’ve noticed that some organizations haven’t updated their sentinel event policy to include all the current TJC requirements. So, the following is a recap of TJC requirements related to sentinel events.
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If you are a psychiatric hospital that uses TJC accreditation for deemed status, you probably received an email communication recently from TJC entitled “Important Update on The Joint Commission Accreditation Process for Psychiatric Hospitals.” This notification discusses some significant changes to survey reports, scoring, and the post-survey process for psychiatric hospitals. These changes were discussed at the Consultants Forum we recently attended at TJC and are now being communicated officially to the field. The following is a summary of the key changes that go into effect June 6, 2016 (only for psychiatric hospitals that use TJC accreditation for deemed status.)
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The scheduling of surveys and composition of survey teams are always topics of interest to our clients, so here are some updates in those areas. Also, be aware of the new Sentinel Event Alert on suicide risk assessment and treatment.
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The Joint Commission Center for Transforming Healthcare recently made available the Oro 2.0 High Reliability Organizational Assessment. The assessment is an online tool designed to assist hospitals in evaluating their progress toward high reliability and support them in attaining the goal of zero patient harm. The web-based tool is available to accredited organizations on their Joint Commission Connect extranet site. The Oro 2.0 Assessment guides the leadership team through a series of questions on key strategic performance issues. It’s based on the High Reliability Maturity Model.
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Effective July 1, 2016, TJC’s Behavioral Health Care Accreditation Program will include standards for case management services provided to individuals being served in a Housing First program. The new standards are designed to assist individuals with serious mental illness, substance abuse disorders, and other behavioral healthcare issues. They are applicable only to TJC accredited behavioral healthcare organizations that provide case management services to for clients in a Housing First program.
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The Joint Commission has finalized new requirements for accredited behavioral health organizations that treat individuals with eating disorders. The new requirements go into effect July 1, 2016. They are the result of collaboration between the TJC Behavioral Health Care Accreditation Program and leaders of prominent eating disorder programs throughout the country. The goal is to […]
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In working with our psychiatric hospital clients, we have noted a standard in the Hospital manual which sometimes gets overlooked. That standard is PC.02.01.19 in the Provision of Care chapter: “The hospital recognizes and responds to changes in a patient’s condition.” The rationale behind this standard is that a significant number of critical inpatient events […]
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As the year winds down, we thought it would be useful to review the top compliance issues encountered by psychiatric hospitals and behavioral healthcare organizations in 2015. However, truth is that the Top Ten list hasn’t changed much and the topics are quite familiar (treatment planning, competencies, pain screening, etc.) So, we decided to take […]
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Effective January 1, 2016 The National Patient Safety Goal on Alarm Management (NPSG.06.01.01) went into effect in January, 2014 for hospitals. 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 […]
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