TJC & CMS News Blog Information
for Hospitals and Behavioral Healthcare
To read articles written prior to January 2015, please view our Newsletter Archive.
Update on TJC Surveying of Ligature Risks
If you are a psychiatric hospital anticipating a TJC survey, it’s important to know the details of how TJC is currently surveying ligature risks. They recently provided an update for the field on this topic in follow-up to their March 2017 communication on the scoring of ligature, suicide and self-harm risks. Here are some highlights from this most recent update.
TJC HR Requirement: Competence Assessment by a Qualified Individual
Twenty-two percent of behavioral health organizations surveyed in 2016 received a survey finding related to competence assessment. Frequently, the finding relates to a staff person or contractor not having their clinical competence assessed by an individual qualified to do so. The relevant standard is HRM.01.06.01 EP 2 in the BH Manual and HR.01.06.01 EP 3 in the Hospital manual. Learn how this standard is typically reviewed by surveyors.
Psychiatric Hospitals: Top Ten Compliance Issues on the SAFER Matrix
Psychiatric hospitals that use TJC accreditation for CMS deemed status were the first organizations to experience the SAFER (Survey Analysis for Evaluating Risk) methodology starting in June 2016. TJC recently published six months of compliance data for these hospitals. Many of the Top Ten issues remain the same but it’s interesting to see how they play out on the SAFER matrix. Here’s some highlights from the TJC data and our own database.
Environment of Care Updates: Exit Signs and Fire Drills
TJC began surveying to the 2012 edition of the National Fire Protection Life Safety Code in November 2016. Resulting changes to the Environment of Care and Life Safety standards went into effect January 2017. One of the changes that went into effect for both the Hospital and Behavioral Health programs is a new requirement for inspection of Exit signs. We are now seeing this issue arising on surveys so let’s clarify the requirement.
Increased Scrutiny of Environmental Safety Risks in Psychiatric Hospitals
The Joint Commission recently announced that it is increasing scrutiny during surveys on ligature, suicide and self-harm risks in psychiatric hospitals and inpatient psychiatric units of med/surg hospitals. Specifically, TJC surveyors will document in their report all observations of ligature or self-harm risks that they identify in the hospital’s environment.
Compliance Catch-Up
From time to time, we update our readers on standards compliance requirements related to commonly challenging issues we see coming up on surveys. So, take a look at the following updates related to vaccines, CLIA certificates, fire drills, continuing medical education and texting of orders, and make sure these don’t become survey pitfalls for you.
Prepare for Focus on Antimicrobial Stewardship during 2017 Hospital Surveys
In our October 2016 newsletter, we covered the new TJC requirements on antimicrobial stewardship. Now, it’s clear that TJC is incorporating a significant emphasis on this topic into the 2017 survey process for hospitals. The recently released 2017 Survey Activity Guide provides information on how surveyors will weave the topic of antimicrobial stewardship into the different sessions.
Changes to TJC Clarification Process Effective January 2017
For many years, TJC has had a process in place whereby an organization can request to “clarify” a survey finding when the organization believes that it was actually in compliance with the applicable standard at the time of the survey and thus should not have been cited as noncompliant. There will continue to be a clarification process but there are some significant changes to the process that go into effect for all accreditation programs effective January 1, 2017.
Psychiatric Hospitals: Prepare for New Antimicrobial Stewardship Standard
In July, 2016 TJC introduced its new standard on antimicrobial stewardship. The standard is contained in the Medication Management chapter (MM.09.01.01) of the Hospital manual and goes into effect January 1, 2017. Antibiotic consumption in psychiatric hospitals is low compared to general hospitals. However, antibiotics have several drug–drug interactions with psychotropic drugs that can lead to adverse events or treatment failure and significantly increase the cost of treatment. Thus, this new standard is relevant for any hospital whose patients are being prescribed antibiotics.
Influenza Vaccination: An Important Compliance Issue for BH Organizations
The TJC requirements for behavioral health organizations to implement influenza vaccination programs went into effect in 2012 and were expanded in 2013. Most BH organizations now have a process for offering influenza vaccination and educating staff about the importance of the vaccine. However, some BH organizations still struggle with meeting all of the TJC requirements in this area and this standard (IC.02.04.01) has now made its way into the Top Five findings for BH organizations for the first half of 2016.