There are a number of important behavioral health care projects we are working on this year and we would like to know what you think. On May 6, we began collecting comments through an online survey regarding the behavioral health care standards for the Standards Improvement Initiative. The goal of this project is to review and refine the standards in order to make them clearer, more objective and more applicable to behavioral health care organizations. To participate, go to www.jointcommission.org/Standards/SII.
In addition, we are preparing to revamp the requirements for people with developmental disabilities. We’ve started a discussion group on WikiHealthCare™, to gather feedback. WikiHealthCare is an online collaborative forum specifically for health care professionals. Visitors post an idea, others comment on it, add to it, and so forth. It’s very easy to use. We are strongly encouraging participation in this exchange, so please forward the link to anyone who you think may be interested.
As always, I am eager to hear what you have to say. I can be reached at mcesaremurphy@jointcommission.org. Have a safe and healthy summer!
Mary Cesare-Murphy, Ph.D.
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The Board of Commissioners has approved new, improved and simplified scoring and decision processes, effective January 1, 2009, for all accreditation and certification programs. The current decision process is primarily based on the volume of survey findings in relation to pre-established thresholds. The new processes:
- Are based on the “criticality” of survey findings. This means that accreditation decisions and the timing of follow-up requirements are judged in relation to the immediacy of the threat to behavioral health care quality and client safety as the result of non-compliance with Joint Commission requirements.
- Reflect an organization’s performance respecting compliance with Joint Commission standards and elements of performance.
Please note that the proposed changes to the scoring and decision processes are still under review by The Joint Commission; final changes will be published by July 1, 2008, on The Joint Commission website.
Tell us what you think
The Joint Commission is seeking input on the behavioral health care standards and elements of performance. Comments will be gathered for six weeks beginning May 6, 2008. To participate, go to www.jointcommission.org/Standards/SII.
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The Joint Commission is encouraging behavioral health care professionals to join in the conversation about developmental disabilities and other behavioral health care topics on its collaborative website ― WikiHealthCare™ .
“The interactive WikiHealthCare forum is set up to enable health care professionals to discuss and share quality improvement ideas and experiences,” says Scott Williams, associate director, Division of Quality Measurement & Research. “We are asking for comments on a number of topics regarding performance expectations for organizations providing services to persons with developmental disabilities. We hope to gather input from providers, clients, their families and other stakeholders.”
The Joint Commission is specifically seeking input on:
- What action(s) are essential to an organization providing safe, quality services for persons with developmental disabilities?
- Should there be different expectations for services for persons with intellectual disabilities and services for persons with pervasive developmental disorders, such as autistic disorder?
- Is there widespread use of the term "intellectual disabilities?"
- Is there widespread use of the term "pervasive developmental disorders?"
- Should there be different types of assessment and treatment approaches, community integration, and person-centered focus?
- What are the most important topics or issues that should be looked at to evaluate the quality and safety of an organization that serves people with intellectual and other developmental disabilities?
The interactive WikiHealthCare forum also enables behavioral health care professionals to discuss and share quality improvement ideas and experiences. Other topics related to quality improvement in behavioral health care include: recovery/quality of life, using outcome data to improve quality, and Failure Mode Effects Analysis in behavioral health care. Participants can also suggest topics. To get started, log on, go to the “Standards Development & Research” area, and select “Developmental Disabilities.” If you have any questions, contact Williams at swilliams@jointcommission.org or Caroline Christensen at cchristensen@jointcommission.org.
What is a wiki? |
"Wiki" is the Hawaiian word for "fast." A wiki is a collection of web pages designed to allow participants to contribute or modify content. For this reason, wikis are often used to facilitate collaborative community websites. The collaborative encyclopedia Wikipedia® is one of the best known wikis. |
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In order to provide residential and partial hospitalization services to TRICARE beneficiaries, behavioral health care facilities and hospitals must be accredited under The Joint Commission’s Behavioral Health Care Accreditation Program and not just under the Hospital Accreditation Program. (TRICARE is the health care program for military personnel and their dependents.)
While current Joint Commission policies allow hospitals with partial hospitalization programs that have an average daily census of 10 or less to choose hospital accreditation without the additional behavioral health care accreditation, this arrangement does not meet TRICARE requirements, according to MAXIMUS (the company that determines whether facilities meet TRICARE requirements).
Joint Commission behavioral health care accreditation is the only recognized accreditation for TRICARE residential treatment centers and partial hospitalization programs. It also is one of the recognized accrediting bodies for substance use disorder rehabilitation facilities. For more information, contact your account representative at (630) 792-3007.
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“How to prepare for your first accreditation survey” is the topic of a free one-hour audio conference on June 11 from noon to 1 p.m. (CT). This program is for behavioral health care organizations new to accreditation or those not yet accredited by The Joint Commission. For more information or to register click here.
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The 2009 accreditation program manuals will be available electronically as “E-ditions” beginning in November 2008. Along with the customary free print copy of the manual, organizations will receive a free E-dition (i.e., single-user license).
The E-ditions will be accessed on the Internet via log-in and password. Features will include key word search capability across one or more manuals, access to every standard in three “clicks,” and the new scoring categories. (Please note that for the behavioral health care program, some features related to ongoing SII improvements will be available in the 2010 E-ditions.) More information, including how organizations will receive the E-ditions, will be available in September.
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The Joint Commission has expanded the window for unannounced surveys to within 18 to 39 months (previously 24 to 39 months) after an organization’s previous survey, effective mid-2008. The Joint Commission’s Accreditation Committee recently approved the methodology for conducting these surveys. The new methodology will take into account Priority Focus Process data across multiple quarters as well as trends in the performance of these data.
The majority of organizations will still be surveyed in the year that their triennial survey would be due,” says Mary Cesare-Murphy, Ph.D., executive director. “A minority of organizations will be surveyed earlier. These outliers represent circumstances where data suggest that client safety and quality are potentially at risk.”
For more information, see the April 2008 issue of The Joint Commission Perspectives or contact your account representative at (630) 792-3007.
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Effective January 1, 2008, The Joint Commission discontinued track record requirements for organizations undergoing initial surveys. These organizations do not need to demonstrate a four-month track record of compliance with the standards at the time of the initial survey or review. Also effective this year is the elimination of Early Survey Policy Option 2 for all programs (except the laboratory program). Please note that track record requirements remain in place for organizations undergoing re-surveys or re-reviews.
While the track record requirements have been eliminated for initial surveys, The Joint Commission still sets minimum requirements for client volume for these surveys and a one year, follow-up survey for high risk/critical services is also required.
Volume requirements
- Most behavioral health care facilities: Five individuals served with at least two active at the time of survey
- Foster care/therapeutic foster care programs: Three foster homes at least two caring for at least one foster child
- Opioid Treatment Program methadone detox programs: Three clients served
High risk/critical services requiring follow-up surveys
- Residential/group home settings that provide services to children and adolescents
- Services that provide mechanical restraints
For more information, see the January issue of The Joint Commission Perspectives.
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Behavioral Health Care: A Primer for Beginners
Provides fundamental information about the standards and accreditation process including the on-site survey, scoring guidelines, periodic performance review, 2008 survey thresholds and accreditation decisions.
August 25, Oakbrook Terrace, Ill.
Behavioral Health Care: Accreditation Essentials
Provides practical strategies and implementation tips, including global approaches to the standards, elements of performance, National Patient Safety Goals, and links to tracers and priority focus areas.
August 26-27, Oakbrook Terrace, Ill.
Save the date! Fifth Annual Behavioral Health Care Conference and Update
December 8-10, Chicago, Ill.
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2008 CAMBHC Subscription Update
Keeps your organization current with the latest accreditation information. Update 1 (March) focuses on changes made as a result of the Standards Improvement Initiative that are effective January 1, 2009.
Update 1 is available for free on the website.
2008 Comprehensive Accreditation Manual for Behavioral Health Care (CAMBHC)
Order code: CBHC08, $265
A Practical Guide to Documentation in Behavioral Health Care
Order code: BHC600, $99
Accreditation Process Guide for Behavioral Health Care
Order code: BHSP06SJ, $119
How to Meet the Most Challenging Joint Commission Requirements for Behavioral Health Care
Order code: MCRBH-06, $75
For information or to order products from Joint Commission Resources, Inc., go to http://store.jcrinc.com/ or call (877) 223-6866.
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BHC Accreditation (630) 792-5790
Standards Interpretation Group (630) 792-5900
BHC Account Representative (630) 792-3007
Customer Service (630) 792-5800
Pricing Unit (630) 792-5115
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