Barrins Bulletin
December 2025
Closing 2025: Reflections on the Work that Matters
Dear Readers,
As 2025 comes to a close, we find ourselves reflecting less on checklists and milestones, and more on the substance of the work behind them.
This has been another year defined by complexity. Regulatory expectations continued to evolve. Survey activity intensified. Staffing pressures, financial constraints, and community needs intersected in ways that left little room for missteps. For many organizations, simply staying steady required focused effort and difficult decisions.
What has stood out most to us this year is not any single standard or requirement, but the seriousness with which healthcare leaders and teams continue to approach their responsibility. Across hospitals, behavioral health organizations, and community-based programs, we have seen a consistent commitment to patient safety, dignity, and compliance—often under circumstances that made the work far from straightforward.
At Barrins, our role remains unchanged. We are not here to interpret standards in the abstract. We are here to help organizations understand how those standards apply in real environments, with real people, and within real operational constraints.
The work is not about perfection; it is about clarity, readiness, and making informed, defensible decisions.
Throughout 2025, our conversations with clients reinforced an important truth: sustainable compliance is built through understanding, preparation, and follow-through—not last-minute fixes or surface-level solutions. Organizations that invest in thoughtful readiness, staff engagement, and practical application are better positioned not only for surveys, but for long-term stability.
As we look ahead to 2026, we know the regulatory landscape will continue to demand attention and adaptability. We also know that the work ahead will require the same steady, experienced approach that has always guided our partnerships.
Thank you for the trust you place in us and for the opportunity to support the important work you do. We look forward to continuing alongside you in the year ahead.
In the spirit of the season, we’re sharing a complimentary tool that will support your compliance with the 2026 Health Care Equity requirements to support your work as you prepare for the year ahead. Please use it as-is or personalize it to your team’s needs.
Click on your gift below to download a copy.
Warm Regards,
Yvonne Rockwood
MBA, MHA, CPHQ
Senior Vice President
Experienced guidance for complex accreditation and regulatory work.
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Joint Commission (JC)
The nation’s primary CMS-deemed hospital and behavioral health accreditor
2025
Launched Accreditation 360 for Psychiatric Hospitals, emphasizing continuous readiness, streamlined standards, increased use of data, and closer alignment with CMS CoPs.
Removed 700+ hospital requirements to reduce redundancy and administrative burden.
2026
Released the 2026 Behavioral Health Care & Human Services (CAMBHC) manual (Oct. 15, 2025), reflecting a routine annual update with clarifications and refinements—not a program redesign.
CIHQ
Hospital Deeming (Psychiatric Hospitals via the Hospital Program)
2025
Continued CMS-driven updates, maintaining close alignment with Medicare Hospital CoPs and CMS SOM guidance.
Sustained focus on condition-level compliance, including patient rights, nursing services, medical staff oversight, and QAPI.
2026
Ongoing incorporation of CMS interpretive guidance, with no new CIHQ-specific requirements.
Continued emphasis on education and summit programming highlighting survey trends and common deficiencies.
CARF
Behavioral Health and Community-based Services
2025
- Refined (not expanded) standards with clearer expectations across programs.
- Greater focus on outcomes and performance measurement, including person-centered results.
- Continued emphasis on equity, access, and cultural responsiveness.
2026
- Ongoing outcomes-driven surveys and continuous quality improvement focus.
- Routine, targeted standards updates aligned with evolving behavioral health and community care models.
- Continued education and guidance based on survey trends.
DNV
Hospital Accreditation (Psychiatric Hospitals)
2025
- Continued integration of CMS CoPs and ISO 9001, reinforcing continuous improvement and leadership oversight.
- Survey focus on system performance (governance, QAPI, risk management) over isolated findings.
2026
- Ongoing emphasis on ISO-based processes, internal audits, and corrective action.
- Continued annual survey cadence and CMS-aligned survey priorities.
COA
Community Behavioral Health & Human Services
2025
- Continued refinement of outcome-focused standards, emphasizing service effectiveness, governance, and accountability.
- Ongoing integration of equity, access, and culturally responsive practice across applicable programs.
2026
- Sustained focus on measurable outcomes and quality improvement rather than checklist compliance.
- Routine, targeted standards updates and continued education tied to survey trends.
Focus Equity Efforts on One Measurable Disparity
When developing or updating your Equity Action Plan, identify one clearly defined health disparity, the population most affected, and one measurable outcome you intend to improve.
Surveyors are looking for evidence of action, monitoring, and leadership, not broad statements of commitment. A focused, data-driven approach demonstrates meaningful progress and regulatory readiness.
Barrins & Associates provides regulatory and accreditation consulting services for the Behavioral Healthcare industry, including psychiatric hospitals and freestanding BH organizations. We specialize in providing survey preparation and continuous survey readiness services to help you provide safe and compliant care.
Founded in 1999 by Anne Barrins, former Joint Commission (JC) surveyor and succeeded by Julia Finken, former JC 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 and Yvonne Rockwood, former Regional Associate Director for the Eastern Business Development Division at the JC for Community Behavioral Health Care Services.
- From Checklist Compliance to a Focus on Outcomes and Value
- How to Improve Equity in Behavioral Health: Steps Providers Can Take
- Beyond Intent: The Operational Imperative of Equity in Psychiatric Hospitals
- Accreditor Insights & Updates: JC, CIHQ, CARF, DNV, COA
- Tip of the Month: Focus Equity Efforts on One Measurable Disparity
- How to Improve Equity in Behavioral Health: Steps Providers Can Take
Congratulations Corner
We applaud our clients who have recently and successfully completed their accreditation or regulatory survey. The achievement of such indicates an aptitude for quality and safety of care. Congratulations to your organization and staff!
CT DMHAS Connecticut Valley Hospital
Why Choose Us?
“Our consultant created a trusting and collaborative feel to the audit and our team felt safe asking sensitive questions that we needed clarification on regarding grey areas due to the subjectivity in clinical interpretation of some standards.“
Chief Operating Officer
Behavioral Health Hospital
Welcome New Clients
Barrins & Associates welcomes the following new clients:
New Jersey Department of Health
- Greystone Park Psychiatric Hospital
Are You Survey Ready?
We can assist you to achieve and sustain accreditation and regulatory compliance in adherence to the JC, DNV, CHIQ, ACHC, CARF, COA, QUAD-A, 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.