Barrins Bulletin
April 2025
Welcome to the April edition of our Behavioral Health and Psychiatric Hospitals Newsletter
Dear Readers,
This month, we’re focusing on a theme that cuts across care settings, disciplines, and decision-making levels: Creating Safe, Seamless Systems of Care in Behavioral Health. From the emergency room to the outpatient clinic, from physical environments to clinical governance, the strength of our behavioral health systems depends on how well we design for safety, quality, and continuity.
Our first article addresses a growing concern across the country—. It’s a reflection of system strain and a call to action for better access, capacity planning, and crisis stabilization options.
Next, we turn our attention to the outpatient behavioral health setting, where environmental risk assessments are essential for maintaining a safe therapeutic space. This proactive approach protects patients and staff alike, and helps organizations meet regulatory standards while honoring their mission.
Finally, we explore the often-overlooked foundation of quality care: medical staff bylaws in psychiatric hospitals. These documents shape the credentialing process, define scopes of practice, and provide a framework for clinical excellence.
As always, thank you for your commitment to advancing behavioral health. We hope this month’s insights spark ideas, conversations, and collaboration within your teams.
As always, we appreciate your input on the newsletter. Please take a moment to share your comments and let us know your thoughts. Additionally, we welcome suggestions for topics you would like to see covered in future issues. We eagerly anticipate hearing from you! Don’t hesitate to forward this newsletter to your colleagues; their insights are invaluable to us as well.
Best Regards,
Julia Finken
RN, BSN, MBA, CPHQ, CLSSMBB
Senior Vice President
Elevating Patient Outcomes: Empowering Healthcare Leaders to Achieve Excellence
When it comes to governing a psychiatric hospital’s medical staff, structure, clarity, and accountability are not just important—they’re required. The Joint Commission (TJC) Standard MS.01.01.01 outlines critical expectations for Medical Staff Bylaws, ensuring that…
Emergency departments are often the first—and sometimes only—point of access for individuals in psychiatric crises. But when inpatient psychiatric beds, crisis services, or outpatient programs are unavailable, patients may wait in the emergency department (ED) for…
Increasingly, care delivery occurs in outpatient environments—Intensive Outpatient Programs (IOPs), Partial Hospitalization Programs (PHPs), and office-based therapy settings—where clients may be acutely ill, at elevated risk of harm to self or others, and navigating…
TJC
The Joint Commission has revised APR.01.03.01 EP 1 for organizations accredited under the Behavioral Health & Human Services Manual and Psychiatric Hospitals accredited under the Hospital Manual. In addition to requiring a written notice within 30 days of a change in ownership, control, location, capacity, and services offered, The Joint Commission has added required notice within 30 days of any change in required licensure. You will want to implement this update.
DNV
Registration is open for the 2025 DNV Healthcare Symposium being held on October 20-23 in Costa Mesa, California. This symposium will bring together leaders in care quality from many different organizations.
Attending is a great way to learn about any updates to NIAHO® accreditation requirements, ask questions of the DNV team, and learn from peer organizations about solutions they’ve designed and implemented for successful outcomes. Register and consider submitting an abstract to present in a breakout session.
CIHQ
A CIHQ Partner webinar, Re-imagining Facility and Compliance Funding: Unlocking Cost Savings, Regulatory Performance, and Reimbursements Through Strategic Upgrades was conducted on April 8, 2025.
It was presented by CEG Solutions who discussed industry practices on funding facilities projects; revealed how strategic upgrades can revolutionize regulatory compliance; presented how a holistic, data-driven program can uncover critical facility system needs; identified how to generate 20% to 70% lower HAIs; identified a 40% reduction in energy costs; and provided information on leveraging energy and operational savings to offset a need for upfront capital.
If you were unable to join live, the webinar recording, Partner Webinar Series CEG April 2025, is available through the CIHQ – ARS & Partners YouTube channel.
ACHC
ACHC manual updates were released April 6, 2025. If you are accredited by ACHC, you will want to review and implement these updates.
They also have opened registration for their 8th Annual Charity Golf Tournament, teeing off on May 19, 2025. Proceeds go to local charities benefiting the safety and well-being of children. Visit their website to learn more.
COA
The 2025 Executive Leadership Institute is being held at Loyola University Chicago Quinlan School of Business in Chicago, IL on June 8-12, 2025. The week-long institute will equip executives and senior-level managers with the knowledge and skills to oversee day-to-day operations and to help prepare for the future and any greater systems change. Register now, as the deadline to sign up is May 1.
The National Institute of Occupational Safety and Health, or NIOSH, a division of the CDC, has published Hazardous Drug Exposures in Healthcare. Here you can view the updated list of hazardous medications dated 2024, the 2023 document for Managing Hazardous Drug Exposures, and another 2023 publication on how NIOSH identifies hazardous drugs – you will want all three (3).
We were founded by Anne Barrins, former Joint Commission surveyor, and are succeeded by Julia Finken, former Joint Commission surveyor, Associate Director of Business Development for the Home Care Program, and Executive Director of Business Development for the Behavioral Health Care and Psychiatric Hospital Programs.
- The Backbone of Medical Staff Governance: What You Need to Know About Joint Commission Standards for Medical Staff Bylaws
- Beyond the Wait: Compassionate and Compliant ED Boarding of Psychiatric Patients
- Creating Safe Spaces: How to Conduct an Environmental Risk Assessment for Outpatient Behavioral Health Settings
- Accreditor Insights & Updates: TJC, DNV, CIHQ, ACHC, COA
- Tip of the Month: NIOSH: Hazardous Medications
Congratulations Corner
We applaud our clients who have recently and successfully completed their Joint Commission Behavioral Health and Human Services Accreditation Survey. The achievement of such indicates an aptitude for quality and safety of care.
Congratulations to your organization and staff!
Welcome New Clients!
Barrins & Associates welcomes the following new clients:
- Brighter Days Ahead
Hear What Our Clients Say
“The Barrins consultant was very knowledgeable regarding the standards and strategies for compliance with the standards. She was extremely helpful in offering suggestions regarding how we can improve our overall practices. I would recommend this consultant to other organizations.“
Are You Survey Ready?
At Barrins & Associates we can assist you to achieve and sustain accreditation and regulatory compliance in adherence to the TJC, DNV, CHIQ, ACHC, CARF, COA, and CMS, standards for psychiatric hospitals and community behavioral health and human services providers. Inquire today about our consulting services. We continue to support your journey toward accreditation and regulatory compliance.
Inquire today about our consulting services.
We continue to support your journey toward accreditation and regulatory compliance.