TJC & CMS News Blog Information
for Hospitals and Behavioral Healthcare
To read articles written prior to January 2015, please view our Newsletter Archive.
Feedback from TJC Hospital Executives Briefings
We attended the annual TJC Hospital Executives Briefings and CMS Update in New York City earlier this month. It was chock full of information on the latest TJC and CMS compliance issues. It was also a glimpse into what some of the key TJC focus areas will be in 2015....
Treatment Plans in Psychiatric Hospitals
As we all know, issues with treatment plans are one of the most frequently cited areas of non-compliance on TJC surveys. This is true for both psychiatric hospitals and behavioral health organizations. Recently, however, a new issue has been identified.
Opportunities for Improvement
Organizations surveyed after July 1, 2014 will see a change in how their findings are written up in their TJC survey reports. There will now be an Opportunities for Improvement section included in the survey report. Included in this OFI section will be single...
TJC Changes to PFIs and Life Safety Equivalencies
[thumbnail alt="Tim O’Rourke, CHFM" type="img-thumbnail" alignment="alignright" image="http://barrins.a3creativeloft.com/wp-content/uploads/TimOrourke-219x300.jpg" ]Tim O’Rourke, CHFM, B&A Engineer[/thumbnail]Barrins & Associates engineer Tim O'Rourke, CHFM...
Competence Assessment in Behavioral Health
During surveys of both psychiatric hospitals and behavioral health organizations, issues continue to arise around how the organization is assessing the competence of its clinical staff. We have seen several survey findings for organizations not clearly defining...
Medication Instructions at Discharge
The TJC focus on the discharge process continues in 2014. During surveys, surveyors will frequently request a sample of closed records. In the past, the focus for closed records was on determining if the discharge summary had been completed on time. More recently,...
High Reliability: Important Topic for TJC Leadership Interview
For several years, the common topic for the leadership interview on the last day of the survey was the five "pillars of leadership" as described in standards LD.03.01.01 - LD.03.06.01: Using data Planning Communicating Changing Performance Staffing This topic is still...
No More Complimentary Standards Manuals
Be aware that effective January 2014 TJC will no longer be mailing complimentary hard copies of the standards manuals and standards updates to accredited organizations. Standards manuals and standards updates will be available to accredited organizations via E-dition...
Suicide Risk Assessment: Patient Bathrooms
During surveys of inpatient psychiatric units (and sometimes in residential programs) TJC surveyors continue to cite suicide risks they identify in the environment. Commonly occurring issues are plastic trash can liners, loopable hardware in bedrooms and bathrooms,...
Competence Assessment by a Qualified Individual
There is a standard tucked into the TJC Human Resources chapter that seems innocuous at first reading but frequently causes challenges on surveys. The standard is HR.01.06.01 Element of Performance # 3 in both the Behavioral Health and Hospital manuals: "Staff with...