TJC & CMS News Blog Information
for Hospitals and Behavioral Healthcare
To read articles written prior to January 2015, please view our Newsletter Archive.
Joint Commission Fire Drill Requirement: Vary the Timing
An important Joint Commission fire drill requirement is you must vary the timing of your drills. Seems simple, right? Surprisingly, many organizations overlook this requirement. As a result, they get a finding on their survey. So, let’s review what’s needed to be in...
Joint Commission Tailored Surveys
Does TJC accredit your organization under more than one accreditation manual? If so, that means you get a Joint Commission “tailored survey.” In a tailored survey, TJC applies standards from different accreditation manuals based on your services and settings. For...
New TJC Performance Improvement Requirements
Get Ready! Effective January 1, 2022, new TJC Performance Improvement Requirements go into effect. They’ll be in both the Hospital Standards PI chapter and the Behavioral Health Standards PI chapter. The new TJC Performance Improvement Requirements essentially “raise the bar” on what TJC expects to see in your Performance Improvement program. So, let’s take a look at the details …
New TJC Workplace Violence Prevention Requirements
Get Ready! Effective January 1, 2022, new TJC Workplace Violence Prevention Requirements go into effect. They apply to all TJC accredited hospitals. Currently, the requirements don’t apply to organizations accredited under the Behavioral Health Care standards. However, we recommend these organizations also review the new requirements to see what best practices they may want to adopt …
Boarding Psychiatric Patients in the ED: Joint Commission Recommendations
Boarding psychiatric patients in the Emergency Department is recognized as a significant problem nationwide. Technically, “boarding” is the process of holding an admitted patient in the ED while waiting for an inpatient bed. Best Practices for Boarding Psychiatric...
Onsite Joint Commission Surveys: July 2021 Update
The number of onsite Joint Commission surveys increases each month as we move out of the COVID-19 pandemic. In June 2021, TJC scheduled 784 onsite surveys. That’s the highest number since they resumed limited onsite survey activity in June 2020. In March 2021, they...
Falls Now Included as Sentinel Events
As we work with clients on survey readiness, we’re noticing some organizations haven’t updated their Sentinel Event policy to include the Joint Commission definition of falls as sentinel events. The new definition went into effect January 1, 2021. Here’s what you need...
NPSG 15 Suicide Prevention: The Monitoring Requirement
As we know, compliance with the requirements of National Patient Safety Goal (NPSG) 15 on Suicide Prevention continues to be a challenge for many organizations. Survey findings related to inadequate suicide risk assessment abound. But what about the requirement to...
SAFER Dashboard Launched by TJC
Ever wonder how your survey results stack up against other similar organizations? TJC has made that easier to do with its new SAFER Dashboard. The SAFER Dashboard is a self-serve data analytic tool. It allows organizations to view their survey data and national...
DNV Has Deeming Authority for Psychiatric Hospitals
DNV Healthcare is now the second Accrediting Organization (after The Joint Commission) to receive deeming authority from CMS for psychiatric hospitals to participate in the Medicare or Medicaid programs. CMS granted deeming authority to DNV in July 2020. CMS’s...