Wonder how your TJC survey results compare with other organizations across the country? At our recent Consultants Forum meeting in Chicago, TJC COO Mark Pelletier shared data on survey results for 2019.

Take a look at the trends across the country. We did a breakdown by Psychiatric Hospitals (Hospital standards) and Behavioral Health Organizations (BH standards.)

Psychiatric Hospitals

TJC Surveys: Condition Level Deficiencies

A Condition Level Deficiency (CLD) means your psychiatric hospital is out of compliance with one of the CMS Conditions of Participation. Either the A Tags or the B Tags. If you use TJC accreditation for CMS deemed status, a CLD means TJC will conduct a follow-up Medicare Deficiency Survey within 45 days.

From January through June 2019, TJC surveyed 103 deemed status psychiatric hospitals. The average number of CLDs per hospital was 1.6. This is just slightly down from the average of 1.8 for 2018.

Overall, the trend for this year is that 49% of psychiatric hospitals receive at least one CLD. And thus a follow-up TJC Medicare Deficiency Survey. This is down from 2018 when the average was 62%

Requirements for Improvement

The average number of Requirements for Improvement (RFIs) for psychiatric hospitals for this period was 28.2. In 2018, it was 30.8. So, it’s trending down just a bit.

By comparison, psychiatric hospitals average less RFIs than med/surg hospitals. Their average is 34.

SAFER Matrix Scoring

For this time period, less than 1% of findings were in the Immediate Threat to Health or Safety category on the SAFER matrix. This category is analogous to CMS’s Immediate Threat to Life designation.

In addition, the number of adverse decisions (Preliminary Denial of Accreditation, Accreditation with Follow-up Survey) is trending down. Good news!

Only 2% of SAFER matrix findings for psychiatric hospitals were in the High Risk and Widespread category. This is a bit less than 2018 when it was 3%. In contrast, 5% of findings for med/surg hospitals were in the High Risk and Widespread category.

The majority of findings for psychiatric hospitals – 39% – were in the Low Risk and Limited category on the SAFER matrix. This is trending similar to 2018 when it was 40%.

However, be aware of an important distinction. It’s not only findings in the High Risk and Widespread category that can drive CLDs. A pattern of findings in the lower risk categories can also result in a CLD.

Trends in TJC Survey Findings

The trends in survey findings for psychiatric hospitals remain consistent in the following clinical areas. We’ve included links to previous posts that may be helpful.

• Mental status exams
• Treatment plans
• Suicide risk assessments
• Discharge summaries
• Medical record documentation
• Neurological exams

The one newcomer to the Top Ten list is storage of food and nutrition products (PC.02.02.03 EP 11.) We’ve definitely seen an uptick of survey findings in this area.

So, be sure you have consistent procedures in place for storage of patient food. Both in patient care areas and in kitchens.

There are some helpful TJC FAQs on this topic. Be sure to check these out:

• Refrigerator Temperature – Patient Care Food Storage
• Refrigerator/Freezer – Monitoring Temperature for Food Storage
• Staff Food and Drink in Patient Care Areas   

Behavioral Health Organizations Surveyed under BH Standards

From January through August, 2109, TJC conducted 747 initial and triennial surveys of behavioral healthcare organizations surveyed under the Behavioral Health standards. So, let’s see what the trends are there.

Requirements for Improvement

The average number of RFIs for BH organizations was 12.2. By comparison, the average for psychiatric hospitals is running 28.2 this year.

SAFER Matrix Scoring

During this time period, none of these BH organizations received a finding of Immediate Threat to Health or Safety. In addition, less than 1% of findings were in the High Risk and Widespread category.

The majority of findings for BH organizations (68%) are in the Low Risk category. This is similar to the 2018 trend.

Trends in TJC Survey Findings

The trends in survey findings for BH organizations remain consistent in the following areas. We’ve included links to previous posts that may be helpful.

• Nutritional screening
• Outcomes measurement
• Treatment plans
• Trauma assessment
• Suicide risk assessments
• Verification of credentials

The one newcomer to the Top Ten list is the initial assessment of staff competence (HRM.01.06.01 EP 3.) This should occur during the orientation period and must be documented.

Ongoing Survey Readiness

So, how do these outcomes relate to ongoing survey readiness? As the saying goes, “Forewarned is forearmed.” Make sure you focus on these areas as part of your ongoing readiness program.

Our Mock Surveys and Continuous Readiness Services cover all these high risk areas. We make sure you’re up to speed on the most recent TJC requirements.

We also provide examples of best practice resources and tools. That’s always much appreciated by our clients!