TJC Survey Gap Analysis
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Gap Analysis for Initial Joint Commission Accreditation

Group of professionals in Joint Commission Gap AnalysisAre you a behavioral healthcare organization seeking initial Joint Commission accreditation? If you’re a psychiatric hospital or freestanding behavioral health program, you may be seeking the gold standard of Joint Commission accreditation. We know the process of preparing for accreditation can be very challenging and our team of expert consultants is here to help.

Many organizations don’t know where to start. Or, how to tackle this challenge efficiently. A thorough gap analysis by experienced consultants is the best place to start your journey toward initial TJC accreditation.

Gap Analysis: Foundation for TJC Accreditation

Barrins & Associates conducts a comprehensive gap analysis for behavioral healthcare organizations seeking initial Joint Commission accreditation. This gap analysis forms the foundation for achieving accreditation. It identifies the specific actions you need to take in order to achieve full compliance with Joint Commission standards, so your organization can achieve successful outcomes.

Initial Joint Commission Accreditation Gap Analysis Process

Our gap analysis provides a baseline evaluation of your current state of compliance with Joint Commission standards. We utilize our structured gap analysis tool and customize it to your organization, to make sure we move forward with the best approach for your specific needs.

Here’s how the process works:

  • We identify the specific Joint Commission requirements applicable to your organization based on your scope of service, client population, and setting. This saves you the time and trouble of trying to figure out exactly which standards apply to you.
  • We send you a Documents List of the specific policies, plans, and other documents we’ll review onsite. You’re clear on exactly what you need to have ready for the consultation.
  • We review your documents prior to the onsite consultation. We get familiar with your operation even before we arrive onsite.
  • We do a conference call with you to plan the agenda and the attendees for the various sessions. You get the right staff involved for the various chapters so nobody’s time is wasted.
  • Once onsite, we present a series of Power Point presentations and educate your staff on the key standards for your organization. Your team gets educated about the requirements needed to earn initial TJC accreditation
  • We review the following components of your operation:
    • Policies and procedures Joint Commission Policies and Procedures
    • Organizational plans (Infection Control, Environment of Care, etc.)
    • Clinical records
    • Performance Improvement data
    • Medication management processes
    • Human Resources files
    • Credentialing files
    • Physical plant
  • We provide immediate feedback to your team. We identify which areas are compliant and which ones need further work to achieve full compliance. Your managers and staff are clear on next steps.
  • We share samples of TJC-compliant policies, plans, and tools. Your team gets help from us to customize these to your setting.
  • We conduct an exit conference with your leadership team. Your leaders are briefed on the key compliance issues and next steps from our initial TJC accreditation consultants.
  • Within three business days, we send you an electronic report. You have a detailed summary of our findings and our recommendations for achieving full compliance.
  • We do a follow-up conference call to review the report. You have the opportunity to clarify any questions about the report and how to move forward.

Gap Analysis for Psychiatric Hospitals

Most psychiatric hospitals seeking initial Joint Commission accreditation use it to obtain deemed status from CMS for Medicare funding. In this case, it’s critical for you to comply not only with Joint Commission standards but also with the CMS Special Conditions of Participation (CoPs) for Psychiatric Hospitals (B Tags.) This is a critical component in helping your organization reach its goal of Joint Commission accreditation.

Our gap analysis for psychiatric hospitals covers all the B Tags. You learn the details of the how TJC surveyors will review your program and your medical records for:

  • Staffing
  • Active treatment
  • Comprehensive assessments
  • Individualized treatment plans
  • Documentation of clinical progress
  • Discharge planning

Gap Analysis for Freestanding Behavioral Healthcare Organizations

Many behavioral healthcare organizations have recognized the value of initial TJC accreditation to their stakeholders. More and more are seeking the gold standard of Joint Commission accreditation because it leads to greater value both for clients and stakeholders.

But getting started can be a challenge for an organization – whether large or small. We’ve worked with behavioral healthcare organizations of all sizes to help them achieve Joint Commission accreditation. Our gap analysis covers all the standards in the 2019 Behavioral Healthcare manual. You get a crystal clear picture of what you need to do to achieve your goal of TJC accreditation.

Why Choose Barrins & Associates for your Joint Commission Initial Accreditation

Our team of specialists has worked with over 300 behavioral healthcare organizations nationwide. We have a 100% track record for initial TJC accreditation. Our company was founded by a former Joint Commission surveyor and has expanded to include other former surveyors who have the same goal of helping your organization. Barrins & Associates has a dedicated team of expert consultants who are here to assist in earning your initial Joint Commission Accreditation.

Get started with us today to plan your first steps toward TJC accreditation. Call us at 1-888-742-4621 to discuss your needs or fill out our online contact form.

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Tap into our 100% success rate for initial accreditation. Schedule your Gap Analysis - the first step in a successful TJC accreditation.