TJC & CMS News Blog Information
for Hospitals and Behavioral Healthcare
To read articles written prior to January 2015, please view our Newsletter Archive.
Changes to TJC Accreditation Process for Psychiatric Hospitals
If you are a psychiatric hospital that uses TJC accreditation for deemed status, you probably received an email communication recently from TJC entitled “Important Update on The Joint Commission Accreditation Process for Psychiatric Hospitals.” This notification discusses some significant changes to survey reports, scoring, and the post-survey process for psychiatric hospitals. These changes were discussed at the Consultants Forum we recently attended at TJC and are now being communicated officially to the field. The following is a summary of the key changes that go into effect June 6, 2016 (only for psychiatric hospitals that use TJC accreditation for deemed status.)
Updates on TJC Topics of Interest
The scheduling of surveys and composition of survey teams are always topics of interest to our clients, so here are some updates in those areas. Also, be aware of the new Sentinel Event Alert on suicide risk assessment and treatment.
Oro 2.0 High Reliability Organizational Assessment
The Joint Commission Center for Transforming Healthcare recently made available the Oro 2.0 High Reliability Organizational Assessment. The assessment is an online tool designed to assist hospitals in evaluating their progress toward high reliability and support them in attaining the goal of zero patient harm. The web-based tool is available to accredited organizations on their Joint Commission Connect extranet site. The Oro 2.0 Assessment guides the leadership team through a series of questions on key strategic performance issues. It’s based on the High Reliability Maturity Model.
Responding to Changes in a Patient’s Condition
In working with our psychiatric hospital clients, we have noted a standard in the Hospital manual which sometimes gets overlooked. That standard is PC.02.01.19 in the Provision of Care chapter: “The hospital recognizes and responds to changes in a patient’s...
Not in the Top Ten Yet but Heads Up!
As the year winds down, we thought it would be useful to review the top compliance issues encountered by psychiatric hospitals and behavioral healthcare organizations in 2015. However, truth is that the Top Ten list hasn’t changed much and the topics are quite...
Psychiatric Hospitals: New Requirements for Clinical Alarm Management
Effective January 1, 2016 The National Patient Safety Goal on Alarm Management (NPSG.06.01.01) went into effect in January, 2014 for hospitals. TJC defines a clinical alarm as “A component of some medical devices that is designed to notify caregivers of an important...
Survey Strategy: Preparation of Documents
The Document Review session has always been a component of TJC surveys. Years ago, it meant the surveyors spent hours poring over documents and, consequently, less time out visiting programs and units. Once the tracer methodology came along, that emphasis shifted (thankfully) and now surveyors spend more time doing tracers and less time on Document Review. However, the materials that are assembled for the Document Review remain important for two reasons.
Cleaning of Medical Equipment: Top Ten Compliance Issue for Hospitals
TJC recently published data on the “Top Ten” compliance issues for the first half of 2015. For hospitals, it was notable that the # 2 issue is the improper cleaning and disinfection of medical equipment, devices, and supplies. 54% of hospitals were cited for this issue. Although psychiatric hospitals have much less medical equipment and supplies than acute care hospitals, we have seen the trend for more citations on this issue with our own psychiatric hospital clients over the past few years. So, it’s an important area to stay on top of as part of your continuous readiness program.
Be Prepared for Closed Record Review during Your Survey
Although it is not a part of the formal agenda, most TJC surveys typically include a review of a sample of closed records in addition to the open record review that takes place during tracer activities. There are specific elements that surveyors are evaluating when they review closed records, including Timeliness of Discharge Summaries, Content of Discharge Summaries, Discharge Instructions and Discharge Information Shared with Other Providers.
Competency Assessment for Group Facilitators
“How do you know this clinician is competent to run these groups?” That was the question asked by the nurse surveyor during the Human Resources interview on a psychiatric hospital survey. She was reviewing the file of an inpatient therapist who was a licensed clinical social worker. The HR Director responded by showing that all of the therapist’s credentials had been verified (license, education, etc.,) but the surveyor kept pushing the issue and asked to speak with the Clinical Director who was the therapist’s supervisor.