Behavioral Healthcare Compliance for Accreditation and Regulatory Requirements: Updates and Resources
See behavioral healthcare compliance posts below from our recent newsletters and access our newsletter archive and behavioral healthcare industry links.
Evaluating Your Culture of Safety
Are you expecting a TJC survey in 2018? If so, be ready for surveyors to explore how your organization has evaluated its Culture of Safety and what you’ve done with the results of that evaluation. We’ve already seen this occurring in 2018 surveys based on feedback from our clients. There are two requirements for conducting this evaluation embedded in the Leadership section of both manuals.
Proposed Revisions to National Patient Safety Goal on Suicide Risk Assessment
TJC has proposed revisions to the current National Patient Safety Goal on suicide risk assessment (NPSG.15.01.01) for both the Hospital and Behavioral Health Care Accreditation Programs. The proposed revisions are available for comment until May 7, 2018, and are summarized in this article.
How One Organization is Meeting the New Outcomes Measurement Requirements
Many organizations and programs accredited under TJC’s Behavioral Healthcare standards are striving to implement the new outcomes measurement requirements effective January 2018. Several readers have asked what instruments folks are using. So, we thought it would be helpful to share the experience of our long-term client Four Winds Hospital in Saratoga Springs, New York. This freestanding psychiatric hospital utilizes the Behavior and Symptom Identification Scale (BASIS-32) for both its adult inpatient units and its adult PHP/IOP programs. They had been using the BASIS-32 for many years for inpatients and then later expanded the tool to the PHP/IOP programs.
Survey Findings Related to Ligature Risks
Intense scrutiny on ligature risks continues for inpatient psychiatric units, both in freestanding psychiatric hospitals and inpatient psychiatric units of medical/surgical hospitals. As the field continues to work toward making these settings ligature resistant, it’s important to know just what is being cited by TJC surveyors these days. Thus, we are providing feedback from recent surveys of our clients so you can use this information to guide your environmental risk reduction efforts.
Reminder: New 2018 Behavioral Health Requirements Now Being Surveyed
For those of you who have organizations and programs surveyed under TJC’s Behavioral Health Care manual, remember there are new requirements effective January 1, 2018, now being surveyed by the BH surveyors. We’ve discussed these in past issues and are summarizing them below, so you can be sure you’ve modified your processes and policies to comply with all the new requirements.
Feedback from TJC Consultants Forum
We were pleased to once again attend the TJC Consultants Forum last month at their headquarters in Oakbrook Terrace, Illinois. The meeting is an annual invitational event and there were 12 consulting firms represented. We heard several informative updates on TJC initiatives.
Increased Scrutiny of Hand Hygiene During Surveys
Be prepared for increased scrutiny and more stringent scoring of hand hygiene compliance during your next TJC survey. Effective January 1, 2018, if a surveyor observes an individual staff person failing to perform hand hygiene during direct patient care, this single observation will be cited as a deficiency resulting in a Requirement for Improvement under the Infection Prevention and Control chapter. This applies across all accreditation programs.
Update on Surveying of Ligature Risks: CMS Memo, TJC Guidance for Non-Hospital BH Settings
Psychiatric hospitals and inpatient psychiatric units of medical/surgical hospitals continue to grapple with the challenge of eliminating suicide risks in their environment and how this will be evaluated during TJC surveys. In December, CMS released a memo on this topic. Likewise, the January 2018 issue of TJC Perspectives contains recommendations regarding the prevention of suicide in non-hospital behavioral health settings.
New Pain Management Standards Effective January 2018
TJC’s new pain management standards are effective January 1, 2018, for all hospitals including psychiatric hospitals. As the 2018 surveys unfold, we expect to see significant emphasis on these new requirements. The following is a summary of key provisions of the new standards. Â
Guidance from The Joint Commission Regarding Ligature Risks
The topic of ligature risks in inpatient psychiatric settings has been a significant challenge for the industry over the past several months following TJC’s increased scrutiny of this issue since March 1. The latest development is that TJC has now published official recommendations on ligature risks in healthcare settings. These Recommendations Regarding Environmental Hazards for Providers and Surveyors were released in a preview communication on October 25 and subsequently published in the November issue of TJC Perspectives. As part of this communication, TJC has formally defined the term “ligature resistant.”