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We were pleased to once again attend the TJC Consultants Forum last month at their headquarters in Oakbrook Terrace, Illinois. The meeting is an annual invitational event and there were 12 consulting firms represented. We heard several informative updates on TJC initiatives including the following:

New Survey Report Format

As of January 1, 2018, the TJC survey report has a new survey report format which is much more customer friendly and easier to navigate. One of the enhancements we think will be most welcome is a page that clearly describes the required follow-up activity from the survey. There is also the ability to download the report into an Excel file. This will make it much easier to develop and track action plans based on the survey findings. See samples below.

TJC Project Refresh presentation Slide 11

TJC Project Refresh presentation Slide 18

New Focus for Leadership Session

There are changes coming to the leadership session held on the last day of survey. It will now focus on how the organization is creating a Culture of Safety which is critical for becoming a High Reliability Organization. Surveyors will be asking organizations about how they have evaluated their Safety Culture and what they have done with the results of that evaluation. This type of evaluation is a current requirement of the Leadership standard LD.03.01.01: “Leaders regularly evaluate the culture of safety and quality using valid and reliable tools.” So, if you have not yet done such an evaluation, we recommend that you roll out this initiative. If you are looking for a tool, the Agency for Healthcare Research and Quality (AHRQ) publishes an excellent one and you can modify it to suit your setting.

Surveying of Ligature Risks

There was continued discussion on the prominent topic of the surveying of ligature risks in inpatient psychiatric units. The good news is that CMS has agreed to a monitoring approach for physical plant changes that have a valid reason (such as capital budget funding requirements) for going beyond the 60 day required timeframe for correction. (See our January newsletter article Update on Surveying of Ligature Risks: CMS Memo for details.) At the same time, be aware that this longer term monitoring approach can only be approved by CMS after the hospital has received a Condition Level finding for Physical Environment and TJC has returned to do the 45 day Medicare Deficiency Follow-up Survey.

It was also clarified that the recent recommendations from the TJC Expert Panel on Suicide Prevention in Health Care Settings regarding residential, partial hospitalization, day treatment, and intensive outpatient settings also apply to outpatient behavioral health clinics. See the January 2018 issue of TJC Perspectives for details and be sure to share this important information with those programs if they are part of your scope of service. Another additional clarification was that the recommendations from Expert Panels # 1 and 2 regarding inpatient psychiatric units also apply to inpatient detox and rehab programs.

BH Accreditation Program Hires More Surveyors

As you may be aware, both initial and triennial surveys for organizations accredited under the BH standards were sometimes running significantly behind in 2017. The good news is that the BH Accreditation Program increased its surveyor cadre by 30% in mid-2017. This has resulted in reduced survey wait times for both types of surveys. So, if you are expecting your triennial survey this year, you can likely expect that you will be surveyed by your three year anniversary date. Remember, though, that the official window of survey availability is 18 to 36 months post your last survey. So, as always, continuous readiness is the key to success!