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Did you know Dr. Mark Chassin, President and CEO of The Joint Commission, recently sent a letter to CEOs of accredited organizations about four areas surveyors will closely scrutinize during Joint Commission surveys? The June 19 letter identifies “four high-risk areas on which our surveyors will focus extra attention during your next survey.”

High-Risk Areas on Joint Commission Surveys

The four areas are suicide prevention, high-level disinfection/sterilization, hemodialysis, and sterile medication compounding. Some of these processes rarely occur in behavioral healthcare settings, but others are relevant. So, let’s discuss where the focus on these will be in upcoming surveys.

Suicide Prevention

Suicide prevention is pertinent for all Joint Commission surveys in behavioral healthcare settings: inpatient, residential, and outpatient. The focus includes both risk assessment and mitigation of ligature risks in the environment and the clinical aspects of suicide risk assessment. Surveyor emphasis on these areas has been persistent over the past 18 months, so organizations should be prepared for those by now.

All too often, the result we still see is a condition-level finding with a follow-up Medicare Deficiency Survey in 45 days. So, be sure to double down your efforts in these areas. Make sure you’ve implemented all the TJC guidelines on ligature risks (see Resources below.) Also, check out our recent article on the suicide prevention tracer that surveyors are conducting When the tracer occurs during your survey, make sure your staff and your documentation can withstand the scrutiny.

High-Level Disinfection (HLD) and Sterilization

HLD and sterilization typically occur in settings such as ERs and ORs, not in behavioral healthcare settings. Yet, we do have some psychiatric hospital clients (e.g., large state hospitals) that provide podiatry and dental services on site. For these services, the standards on HLD and sterilization would apply. Indeed, some of these hospitals have had adverse findings on their Joint Commission Surveys (including an Immediate Threat to Life) for lack of instrument disinfection in these areas.

Even if you don’t perform these types of procedures, prepare for more intense scrutiny on the cleaning/disinfection of medical equipment and supplies. This includes glucometers, stethoscopes, and blood pressure monitors. For more survey feedback, see our recent post “Joint Commission Puts Infection Control Issues High on Radar.”

Sterile Medication Compounding and Hemodialysis

Sterile medication compounding does not typically occur in behavioral healthcare settings. We know some state hospitals that provide hemodialysis on-site through contracted vendors. In this case, the hospital needs to follow the CDC guidelines for dialysis safety.


Suicide Prevention

TJC Perspectives: November 2017 and January, February, and March 2018 issues available on your TJC Connect site (for accredited organizations.)

FAQ on ligature risks on the TJC website

High-Level Disinfection and Sterilization

HAI portal for disinfection and sterilization

Quick Safety 33: Improperly sterilized or HLD equipment — a growing problem

“On Infection Prevention & Control: A Growing Patient Safety Concern: Improperly Sterilized or High-Level Disinfected Equipment”

Also, check out “4-1-1 on Survey Enhancements” on Joint Commission Online for a more in-depth look at these high-risk areas.