JC-Standards Overview Behavioral Health Care - Joint Commission
JC-Standards Overview Behavioral Health Care - Joint Commission
JC-Standards Overview Behavioral Health Care - Joint Commission
You also want an ePaper? Increase the reach of your titles
YUMPU automatically turns print PDFs into web optimized ePapers that Google loves.
© Copyright, The <strong>Joint</strong> <strong>Commission</strong><br />
<strong>Joint</strong> <strong>Commission</strong><br />
<strong>Behavioral</strong> <strong>Health</strong> <strong>Care</strong> Accreditation<br />
August 07, 2012<br />
<strong>Standards</strong> <strong>Overview</strong><br />
Peggy Lavin, LCSW<br />
Senior Associate Director <strong>Behavioral</strong> <strong>Health</strong> Program<br />
Cynthia Leslie, APRN, BC, MSN<br />
Associate Director, <strong>Standards</strong> Interpretation Group<br />
Evelyn Choi, MS<br />
Senior Accreditation Specialist
© Copyright, The <strong>Joint</strong> <strong>Commission</strong><br />
The <strong>Joint</strong> <strong>Commission</strong>:<br />
Independent, not for profit, non-governmental<br />
organization<br />
Accrediting behavioral health organizations since 1969<br />
Over 1,900 behavioral health organizations accredited<br />
Our focus: helping organizations help the individuals<br />
they serve<br />
2
© Copyright, The <strong>Joint</strong> <strong>Commission</strong><br />
<strong>Behavioral</strong> <strong>Health</strong> <strong>Care</strong><br />
Accreditation Program<br />
‣ Requirements found in Comprehensive Accreditation<br />
Manual for <strong>Behavioral</strong> <strong>Health</strong> <strong>Care</strong> (CAMBHC)<br />
‣ Based on a Recovery/Resilience Concepts<br />
‣ Accredited organizations range from small single- service<br />
to complex multiple-service providers<br />
3
© Copyright, The <strong>Joint</strong> <strong>Commission</strong><br />
State Recognitions for<br />
<strong>Joint</strong> <strong>Commission</strong>’s<br />
<strong>Behavioral</strong> <strong>Health</strong> <strong>Care</strong> Accreditation<br />
• 189 Distinct administrative agencies within 48 states<br />
and District of Columbia<br />
• Examples:<br />
– Oklahoma<br />
– Ohio<br />
– North Carolina<br />
4
© Copyright, The <strong>Joint</strong> <strong>Commission</strong><br />
<strong>Joint</strong> <strong>Commission</strong><br />
Accreditation Requirements<br />
Guidance for Good Practices<br />
5
© Copyright, The <strong>Joint</strong> <strong>Commission</strong><br />
Accreditation Requirements<br />
Includes:<br />
Accreditation Participation Requirements<br />
National Patient Safety Goals<br />
<strong>Standards</strong> and Elements of Performance<br />
Sentinel Event Policy<br />
6
© Copyright, The <strong>Joint</strong> <strong>Commission</strong><br />
Accreditation Participation Requirements<br />
Specific requirements:<br />
For participation in the accreditation process<br />
For maintaining an accreditation award<br />
7
© Copyright, The <strong>Joint</strong> <strong>Commission</strong><br />
Examples of<br />
Accreditation Participation Requirements<br />
When requested, organization provides official<br />
report of licensing body<br />
Organization notifies consumers and staff that they<br />
may contact The <strong>Joint</strong> <strong>Commission</strong> with concerns<br />
about safety or quality of care, treatment or services<br />
of individuals served<br />
Organization does not misrepresent information<br />
provided in the accreditation process<br />
8
© Copyright, The <strong>Joint</strong> <strong>Commission</strong><br />
National Safety Goals<br />
Requirements that highlight problematic areas in<br />
behavioral health care<br />
Applicability determined by care, treatment, or<br />
services provided<br />
Goal applicable to organizations accredited<br />
under the Comprehensive <strong>Behavioral</strong> <strong>Health</strong><br />
<strong>Care</strong> Accreditation Manual:<br />
– Two identifiers of individual<br />
– Medication reconciliation<br />
– Hand hygiene<br />
– Suicide risk assessment<br />
9
© Copyright, The <strong>Joint</strong> <strong>Commission</strong><br />
<strong>Joint</strong> <strong>Commission</strong><br />
<strong>Behavioral</strong> <strong>Health</strong><br />
<strong>Standards</strong> Development<br />
<strong>Standards</strong> represent a national consensus<br />
Expert panels provide feedback<br />
– Professional and Technical Advisory Committee<br />
– Advisory Councils<br />
Web-based field review of standards changes<br />
10
© Copyright, The <strong>Joint</strong> <strong>Commission</strong><br />
<strong>Standards</strong><br />
<strong>Standards</strong> are:<br />
General performance expectations<br />
General structure or process<br />
Goal<br />
11
© Copyright, The <strong>Joint</strong> <strong>Commission</strong><br />
Elements of Performance<br />
How standards are evaluated:<br />
Specific performance expectation<br />
Specific structure/process<br />
Objectives<br />
Scored during the On-Site Survey<br />
12
© Copyright, The <strong>Joint</strong> <strong>Commission</strong><br />
Standard Scoring<br />
Elements of Performance are scored<br />
An organization is either in compliance<br />
or not in compliance with a standard<br />
13
© Copyright, The <strong>Joint</strong> <strong>Commission</strong><br />
<strong>Standards</strong> Applicability Process<br />
Common <strong>Standards</strong> apply to all organizations<br />
Specific Program/Setting <strong>Standards</strong> differ from<br />
program/setting to program/setting<br />
Specific Population/Service <strong>Standards</strong> differ from<br />
population to population<br />
Medication Management <strong>Standards</strong> are specific to<br />
each organization’s level of involvement<br />
Applicability grids are in the accreditation<br />
manual – print or electronic<br />
14
© Copyright, The <strong>Joint</strong> <strong>Commission</strong><br />
Specific Programs and Settings<br />
Addictions<br />
Case management<br />
Corrections<br />
Crisis stabilization<br />
Family pres/wraparound<br />
Forensics<br />
Foster care<br />
Therapeutic foster care<br />
Community Support<br />
Therapeutic schools<br />
Eating Disorders<br />
Outpatient<br />
Day programs<br />
Transitional/Supervised living<br />
Residential/Group homes<br />
Outdoor<br />
Technology-based<br />
Opioid treatment<br />
Adult day care<br />
Vocational rehab.<br />
15
© Copyright, The <strong>Joint</strong> <strong>Commission</strong><br />
Electronic Manual<br />
20
22<br />
22
© Copyright, The <strong>Joint</strong> <strong>Commission</strong><br />
23
25<br />
© Copyright, The <strong>Joint</strong> <strong>Commission</strong>
© Copyright, The <strong>Joint</strong> <strong>Commission</strong>
© Copyright, The <strong>Joint</strong> <strong>Commission</strong><br />
View a short video that will walk you<br />
through these steps:<br />
http://www.jcrinc.com/BHC-Service-Profile/<br />
For organizations that are not yet accredited,<br />
please contact Evelyn Choi for complimentary<br />
access<br />
27
© Copyright, The <strong>Joint</strong> <strong>Commission</strong><br />
Required Written Documentation<br />
<br />
<br />
<br />
“RWD” Chapter found in CAMBHC print and electronic<br />
manual<br />
Identifies accreditation requirements requiring written<br />
documentation (policies, procedures, criteria, guidelines)<br />
Can be used as a checklist to achieve or maintain<br />
compliance<br />
28
© Copyright, The <strong>Joint</strong> <strong>Commission</strong><br />
Required Written Documentation<br />
Documentation icon D also found next to all Elements<br />
of Performance that require written documentation<br />
This icon appears in all versions of the Accreditation<br />
Manual (print, on-line, standards-only spiral-bound)<br />
29
© Copyright, The <strong>Joint</strong> <strong>Commission</strong><br />
Top Compliance Issues<br />
CTS.02.01.09 The organization screens<br />
all individuals served for physical pain.
© Copyright, The <strong>Joint</strong> <strong>Commission</strong><br />
CTS.02.01.11 The organization The<br />
organization screens all individuals<br />
served for their nutritional status.<br />
31
© Copyright, The <strong>Joint</strong> <strong>Commission</strong><br />
CTS.03.01.03 The organization has a<br />
plan for care, treatment, or services<br />
that reflects the assessed needs,<br />
strengths, preferences, and goals of<br />
the individual served.<br />
32
© Copyright, The <strong>Joint</strong> <strong>Commission</strong><br />
CTS.04.03.33 For organization<br />
providing food services: The<br />
organization has a process for<br />
preparing and/or distributing food and<br />
nutrition products.<br />
33
© Copyright, The <strong>Joint</strong> <strong>Commission</strong><br />
EC.02.06.01 The organization<br />
establishes and maintains a safe,<br />
functional environment.<br />
34
© Copyright, The <strong>Joint</strong> <strong>Commission</strong><br />
HR.01.06.01 Staff are competent to<br />
perform their responsibilities.<br />
35
© Copyright, The <strong>Joint</strong> <strong>Commission</strong><br />
HR.02.01.03 The organization assigns<br />
initial, renewed, or revised clinical<br />
responsibilities to staff who are<br />
permitted by law and the organization<br />
to practice independently<br />
36
© Copyright, The <strong>Joint</strong> <strong>Commission</strong><br />
MM.03.01.01 The organization safely<br />
stores medications.<br />
37
© Copyright, The <strong>Joint</strong> <strong>Commission</strong><br />
NPSG15.01.01 Identify individuals at<br />
risk for suicide<br />
38
© Copyright, The <strong>Joint</strong> <strong>Commission</strong><br />
RC.01.01.01 The organization<br />
maintains complete and accurate<br />
clinical/case records.<br />
39
© Copyright, The <strong>Joint</strong> <strong>Commission</strong><br />
NPSG15.01.01<br />
The organization identifies safety risks<br />
inherent in the population of the<br />
individuals it serves.<br />
Identify individuals at risk for suicide.<br />
40
© Copyright, The <strong>Joint</strong> <strong>Commission</strong><br />
EP1 Conduct a risk assessment that<br />
identifies specific characteristics of<br />
children/youth and environmental<br />
features that may increase or<br />
decrease the risk of suicide/harm to<br />
self.<br />
41
© Copyright, The <strong>Joint</strong> <strong>Commission</strong><br />
Screening = Process of determining<br />
whether child/youth has certain risk<br />
factors requiring assessment.<br />
Trained staff<br />
Date to be collected<br />
Trigger points<br />
42
© Copyright, The <strong>Joint</strong> <strong>Commission</strong><br />
What questions do you want to ask to<br />
determine if a child/youth is in danger<br />
of harm to self?<br />
Many tools – Choose questions that<br />
apply to your agency<br />
Consider a standardized tool<br />
Is the assessment age appropriate?<br />
43
© Copyright, The <strong>Joint</strong> <strong>Commission</strong><br />
2012 Upcoming<br />
Complimentary Webinars*<br />
September 11 - How to Achieve Accreditation<br />
November 13 - The On-site Survey Process<br />
December 11 – Provider Roundtable<br />
* Already conducted 2012 webinars posted on BHC website<br />
44
<strong>Joint</strong> <strong>Commission</strong><br />
<strong>Behavioral</strong> <strong>Health</strong> <strong>Care</strong> Accreditation<br />
The <strong>Joint</strong> <strong>Commission</strong>’s Gold Seal of Approval TM means<br />
your organization has reached for and achieved the highest<br />
level of performance recognition available in the behavioral<br />
health field.<br />
45
© Copyright, The <strong>Joint</strong> <strong>Commission</strong><br />
<strong>Behavioral</strong> <strong>Health</strong> <strong>Care</strong> Accreditation Team<br />
Mary Cesare-Murphy, PhD<br />
Executive Director<br />
mcesaremurphy@jointcommission.org<br />
630/792-5790<br />
David Wadner, PhD<br />
Field Director<br />
dwadner@jointcommission.org<br />
630/792-5788<br />
Peggy Lavin, LCSW<br />
Senior Associate Director<br />
plavin@jointcommission.org<br />
630/792-5411<br />
Cynthia Leslie, APRN, BC, MSN<br />
<strong>Standards</strong> Interpretation Group<br />
630/792-5982<br />
Evelyn Choi, MS<br />
Senior Accreditation Specialist<br />
echoi@jointcommission.org<br />
630/792-5866<br />
Merlin Wessels, LCSW<br />
<strong>Standards</strong> Interpretation Group<br />
630/792-5899<br />
46
© Copyright, The <strong>Joint</strong> <strong>Commission</strong><br />
What do our accredited customers say?<br />
“We are under constant pressure to do more with<br />
less. <strong>Joint</strong> <strong>Commission</strong> requirements are the<br />
standards we use to assure we don’t sacrifice<br />
quality or safety as we change to meet new<br />
demands. They are the center around which we<br />
organize our systems.”<br />
Susan Rushing, Ph.D.<br />
CEO<br />
Burke Center, Lufkin, TX<br />
47
© Copyright, The <strong>Joint</strong> <strong>Commission</strong><br />
What do our accredited organizations say?<br />
“The <strong>Joint</strong> <strong>Commission</strong>’s self-assessment process<br />
makes us take a close look at the uniformity of care and<br />
services. It makes us confident that patients receive<br />
the same quality care regardless of site, setting, or level<br />
of care. It helps you find real areas of improvement and<br />
stay survey-ready all the time.”<br />
Diane Buchter<br />
Senior VP, COO<br />
The Renfrew Center, Philadelphia, PA<br />
48
© Copyright, The <strong>Joint</strong> <strong>Commission</strong><br />
What do our accredited organizations say?<br />
“We chose The <strong>Joint</strong> <strong>Commission</strong> because we felt<br />
they are the best accrediting agency available. The<br />
<strong>Joint</strong> <strong>Commission</strong> name is powerful and that gives<br />
us an advantage with licensure, insurance, referrals<br />
and our reputation in general.”<br />
Michael Berrett, PhD<br />
CEO, President<br />
The Center for Change<br />
49
© Copyright, The <strong>Joint</strong> <strong>Commission</strong><br />
What do our accredited organizations say?<br />
“The <strong>Joint</strong> <strong>Commission</strong> has been very user-friendly,<br />
more so than other organizations I’ve worked with.<br />
They have a lot of good resources. And our account<br />
executives have been wonderful at getting back to us<br />
quickly whenever we have questions. They’ve been a<br />
great support throughout the entire process.”<br />
Gina Palmer<br />
Compliance Coordinator<br />
Magnolia Creek Treatment Center<br />
50
© Copyright, The <strong>Joint</strong> <strong>Commission</strong><br />
What do our accredited customers say?<br />
“I am always impressed by the experience, patience,<br />
and thoroughness of our surveyors. With The <strong>Joint</strong><br />
<strong>Commission</strong> as a partner, I feel like we have a wise<br />
mentor prodding us to do better, to think more clearly,<br />
and to be more efficient.”<br />
Dustin Tibbitts,<br />
Executive Director<br />
InnerChange New Haven, Provo, UT<br />
51
© Copyright, The <strong>Joint</strong> <strong>Commission</strong><br />
What do our accredited organizations say?<br />
“We have made several very positive changes as a<br />
result of opportunities identified in our survey. And<br />
the surveyors’ willingness to respond to questions<br />
and share “best practices” observed in other<br />
accredited facilities enhances the value of the<br />
survey process.”<br />
Andrew L Braun, MBA<br />
Executive Director<br />
Eating Recovery Center<br />
52
© Copyright, The <strong>Joint</strong> <strong>Commission</strong><br />
What do our accredited customers say?<br />
“The <strong>Joint</strong> <strong>Commission</strong> Gold Seal tells our staff, our<br />
consumers, our payers, and our contractors that we<br />
mean business, that we mean quality. That by coming<br />
to us, they can expect a standard of excellence that’s<br />
driven by an organization that is synonymous for<br />
quality not only in our country, but around the world.”<br />
Michael Flora<br />
President and CEO<br />
Ben Gordon Center, DeKalb, IL<br />
53