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Are you aware that The Joint Commission updated the standard (LD.04.02.03 EP1) addressing ethical issues in healthcare? This is an important change to note for both Hospitals and Behavioral Health Care organizations.

In fact, this update does not introduce a new requirement or new expectations for compliance, but rather reinforces a long-standing expectation for Joint Commission accredited health care organizations. The revised EP will be published in the fall interim 2023 E-dition.

Joint Commission Leadership Standard Highlights the Need for Ethical Principals

Accordingly, this update emphasizes the importance of ethical principles in guiding healthcare organizations’ business practices. It highlights the need for healthcare professionals to develop and implement processes that allow staff, patients/individuals served, and families to address ethical issues or issues prone to conflict.

Ethical Issues to Consider in Behavioral Health Practice

Furthermore, it is important to think about the important ethical issues encountered in your behavioral healthcare setting. One of the primary concerns is informed consent. Patients/individuals served have the right to understand and agree to the treatment they will receive. While the provider may feel that treatment is necessary, it is critical to respect the patient’s autonomy and avoid any action that may be seen as coercive or forced treatment. Providers have a duty to protect patient confidentiality to prevent stigma and discrimination when considering access and equity to care. Finally, business processes like billing, financial practices, marketing, and sales activities must be based on generally accepted business practices.

Ethical Process Sample Outline for Behavioral Healthcare Organizations

Subsequently, develop and implement an ethical process that is practical and meaningful for your organizations’ staff, leaders and patients/individuals served. First, establish ethical principles and standards. Next, develop policies and procedures around these principles. Provide education and training to staff and leaders. Additionally, implement an ethical decision-making framework to respond to ethical issues and breaches. Monitor and audit the effectiveness of the framework and continue to improve the framework over time.

Additional Ethical Practices Resources

Do not forget, the Joint Commission Health Equity standard and EPs have implications for ethical practices. Look at the previous Barrins & Associates Health Equity posts for more information.

Implications of Updated Standard (LD.04.02.03 EP1) for your Joint Commission Survey

Joint Commission surveyors will review your process for upholding ethical practices through individual tracer and system tracer activities. During individual tracers, surveyors will review policies/procedures, interview staff, interview patients/individuals served and review clinical/case records.

Surveyors will further explore gaps they have identified in the implementation of your ethics processes during the Leadership Session. Be prepared for these tracer and leadership activities by ensuring that leaders, staff, and patients/individuals served know and understand what steps they can take when faced with an ethical issue.

Barrins & Associates Consultation

We’ve incorporated the development and implementation of ethical practices into our 2023 Mock Survey and Continuous Readiness Consultations. We continue to be your partner in achieving and sustaining Joint Commission Accreditation and regulatory compliance.