Anyone who has ever had a bad day knows that a tail-wagging, face-licking greeting from a furry companion can dispel a foul mood in an instant.
We saw this first-hand when Joint Commission employee, Leslie LaBelle, held an employee in-service on Delta Society Pet Partners. The mission of Delta Society is to use animals to help people improve their health, independence and quality of life. LaBelle introduced us to Jackson, a soft coated wheaten terrier, who accompanies her on visits to hospice patients. “Well actually,” she admitted ruefully, “He’s the star of the show. I’m really just there as transportation.”
When she’s not chauffeuring Jackson, LaBelle is an associate director in the Department of Education Programs. She explained the training, skills and time requirements necessary to be a Pet Therapy Partner. The employees couldn’t take their eyes off the well-mannered canine and afterwards, everyone got a chance to pet him. You, too, can meet Jackson and exchange your thoughts about using animals in behavioral health care at a breakfast briefing called, “Healthy Tails” at the upcoming Annual Behavioral Health Care Conference, Dec. 9 and 10 in Chicago.
We are offering many other innovative seminars and programs during the conference, including separate tracks for freestanding and inpatient psychiatric organizations. You’ll even get a chance to hear new Joint Commission President Mark Chassin, M.D., M.P.P., M.P.H., give the keynote address. More details about the conference are on page two, or you can check out the brochure. Jackson and I hope to see you there!
Mary Cesare-Murphy, Ph.D.
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The Joint Commission has been awarded a three-year grant from the Department of Health and Human Services, Substance Abuse and Mental Health Services Administration (SAMHSA) to partially subsidize the cost of accreditation surveys and education programs for opioid treatment programs (OTPs). Nationwide, The Joint Commission accredits more than 340 OTPs, which provide rehabilitation and medical support specifically for individuals addicted to opioid drugs.
“These funds will help opioid treatment programs remain in continuous accreditation compliance and improve the quality and safety of the care they provide to their clients,” says Megan Marx, M.P.A., associate director, Opioid Treatment Program Accreditation Project.
The SAMHSA grant also funds free, web-based audio conferences for OTPs. The 2008 programs are:
- "Challenging standards," Sept. 24, 11:30 to 1:00, CT
- "2009 National Patient Safety Goals," Oct. 15, 11:30 to 1:00, CT
- "Individualized Treatment Planning," Nov. 19, 11:30 to 1:00, CT
OTPs should call Customer Service at (877) 223-6866 to register for the free programs. If you have questions about OTP accreditation, contact Megan Marx at mmarx@jointcommission.org or (720) 348-0672.
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The 2009 Behavioral Health Care Leadership and Life Safety Code standards are available online. These were the first chapters revised as a result of the Standards Improvement Initiative for organizations accredited under the Behavioral Health Care Accreditation Manual. The standards take effect January 1, 2009 and have been placed online to give organizations time to become familiar with the new language, ordering and numbering.
Other developments to look for in the coming months:
- Single-user license, electronic E-ditions of the accreditation manuals in late 2008.
- Color-coded tabs added to 2009 print manuals to distinguish standards and requirements from accreditation policies and procedures.
- Changes in the scoring and decision process effective January 1, 2009 for all accreditation and certification programs.
In 2010, BHC organizations will see further improvements including:
- Program-specific language in the Behavioral Health Care Accreditation Manual.
- With E-ditions, the ability to sort relevant standards and elements of performance applicable to the services/programs provided by thel organization.
- Links from certain elements of performance to associated requirements in other chapters.
- Standards and EPs related to a focused area of improvement placed in relevant chapters.
The Joint Commission is asking for feedback on the proposed revisions to the chapters for Infection Prevention and Control, Information Management and Performacne Improvement for the Behavioral Health Care, Laboratory and Long Term Care programs. Click here to participate.
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Ed Smith, R.N., M.S.N., associate director
Standards Interpretation Group
Q: Can I use a Failure Mode and Effects Analysis to meet the requirements of standard PI.3.20?
A: Yes. The standard requires: An ongoing, proactive program for identifying and reducing unanticipated adverse events and safety risks is defined and implemented. This is the definition of a Failure Mode and Effects Analysis. Since it is a proactive activity, using an FMEA avoids hindsight bias and the fear of disclosure, embarrassment, blame and punishment that can happen after an event because adverse events are prevented from occurring in the first place.
The elements of performance for PI.3.20 provide a handy “how-to” guide for how to conduct an FMEA. In addition, ask yourself the following questions to verify compliance:
• Within the last year, was a high-risk process selected for analysis?
• Was the process selected proactively (before there was a problem)?
• Could we demonstrate how each element of performance was addressed?
• What method was used to monitor the effectiveness of the redesigned process?
If you have questions regarding this or any other standard, please contact the Standards Interpretation Group at (630) 792-5900 or submit them via the online form.
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Changes to the 2009 National Patient Safety Goals for the Behavioral Health Care Accreditation Program include new language related to existing requirements for medication reconciliation. See the full text.
The Joint Commission wants to know your opinion about its Speak Up client safety program. Since its launch in 2002, the program has grown to include 10 brochures and four posters, as well as Spanish language versions of all brochures. Please take a few moments to take the short survey, which has a maximum of 18 questions. For more information about Speak Up, visit the website.
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“Sustaining Organizational Momentum to Excellence”
December 9-10, Chicago, Ill.
The conference provides real-world scenarios and best practices to prepare your staff to meet the challenging issues in behavioral health care. You’ll learn:
- How to use Lean methodology and Six Sigma techniques
- What evidence-based practices are on the SAMHSA list
- Ways to prepare your organization and staff for emergency situations
- What are the current requirements for medication reconciliation and polypharmacy
“Leading the way to quality and safety: Maximizing your accreditation efforts”
December 8, Chicago, Ill.
Before the Annual Conference, you can take part in this update that gives the latest information about changes to the standards and requirements.
- Learn about changes to the scoring system
- See a demonstration of the new electronic standards manual
- Apply leadership concepts related to the 2009 standards within your organization
- Develop effective plans to meet medication-related accreditation requirements
Early bird and team discounts are available. See the details .
Joint Commission Resources is seeking proposals for posters of promising practices, research findings, or uses of data to improve performance within behavioral health care settings to be presented at the Fifth Annual Conference on Behavioral Health Care. Abstracts must be received no later than October 1, 2008. For more information go to http://www.jcrinc.com/32206 and click on “Behavioral Health Care Conference Call for Poster Presentations.”
Coming soon! 2009 Accreditation Manual for Behavioral Health Care
Order code: BHC09, $110
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) 792-5411
Standards Interpretation Group (630) 792-5899
BHC Account Representative (630) 792-3007
Customer Service (630) 792-5800
Pricing Unit (630) 792-5115
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