TJC & CMS News Blog
Information for

Scheduling of Behavioral Health Surveys

Initial Surveys

The TJC BH Accreditation Program has seen a significant increase in applications for BH accreditation. In speaking recently with Tracy Collander Executive Director of the BH Accreditiaotn Program, she indicated that in some cases, it may sometimes take up to 120 days from the “ready date” given by the organization for TJC to conduct a survey. If you are in the process of applying for BH accreditation, stay in close communication with your TJC account executive about your estimated ready date and the timeline for your initial survey. TJC will do their best to schedule your initial survey as close as possible to your requested date.

Triennial Surveys

A few of our clients (BH organiztions; non-hospital based) have recently experienced the situation in which their triennial survey has not taken place by 36 months post the date of their last triennial survey. Although uncommon, this may occur and, as noted above, the TJC BH Accreditation Program has seen a significant increase in applications. They are working diligently to keep up with the volume and schedule triennial surveys within the window of survey availability and with attention to the organization’s blackout dates. Best advice is to stay in close touch with your TJC account executive.


Sentinel Event Alerts

TJC has published a new Sentinel Event Alert on preventing suicide in healthcare settings: Detecting and Treating Suicide Ideation in all Settings.

The Alert provides updated information on suicide risk assessment tools and successful projects. It also includes eight specific recommendations for suicide risk assessment and treatment in primary care, emergency care, and behavioral health settings. Notably, the specific recommendations for behavioral health settings include developing treatment and discharge plans that directly target suicidality and utilize evidence based interventions. While many of us are familiar with much of this material, I encourage your clinical leadership to closely review these recommendations and evaluate how well your current practices compare to the TJC recommendations. Lastly, there is an extensive bibliography that provides a host of resources on this important topic.


Survey Teams for Psychiatric Hospital Surveys

The typical surveyor complement for triennial surveys of psychiatric hospitals is a physician, a nurse, and a Life Safety surveyor. Sometimes, for very small hospitals, we have seen either a physician or a nurse conduct a solo survey (in addition to the Life Safety surveyor.) However, in the last two months we have had two sizable psychiatric hospital clients whose triennial surveys were conducted by two nurse surveyors (and the Life Safety surveyor.) While not anticipated to be a common occurrence, TJC indicated that they are currently recruiting for physician surveyors and that sometimes, based on scheduling demands, may need to have these surveys conducted by two nurse surveyors. These nurse surveyors are a specific group of nurses with psychiatric experience who have been trained to conduct surveys of psychiatric hospitals.