The start of a new year is an ideal time to transition from the old to the new, which is why it’s the perfect time to introduce our new branding program.
After more than 19 years as the Joint Commission on Accreditation of Healthcare Organizations, we have shortened our name to The Joint Commission. This reflects not only common usage, but common sense. The name change more accurately captures the diversity of organizations eligible for Joint Commission accreditation. It also signifies that we are moving beyond a traditional approach into a wider range of accreditation and certification programs.
To go along with our new name, the logo has been updated and refreshed. The graphic contains four colored triangles representing the four elements of the cycle for performance improvement (plan, do, study, act). The four triangles form an arrow pointing upward to reflect The Joint Commission’s commitment to continuous improvement. I believe these changes will be good for our behavioral health care customers.
Other projects on the horizon for the behavioral health care program include:
- Revisions to the Opioid Treatment Program standards to reflect changes made to the CSAT Guidelines for the Accreditation of OTPs
- Revisions to the leadership chapter and the emergency management standards
- A behavioral health care “sit-with” seat on The Joint Commission Board of Commissioners
Also, as noted in the article on this page, the e-mail addresses at The Joint Commission have changed. Mine is now mcesare-murphy@jointcommission.org. Please use it to let me know what you think about our new look.
Mary Cesare-Murphy, Ph.D.
Executive Director
Behavioral Health Care Accreditation Program
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In January, The Joint Commission unveiled its new branding initiative with an abbreviated name and a newly redesigned logo. Specific changes include:
- The name has been shortened from the Joint Commission on Accreditation of Healthcare organizations to The Joint Commission.
- New logos for The Joint Commission, Joint Commission Resources, Joint Commission International, and the International Center for Patient Safety.
- New Gold Seal of Approval™.
- Website redesign.
- The “Jayco” extranet has been renamed “The Joint Commission Connect.” It is being redesigned and will launch in the second quarter of 2007.
- BHC News redesign.
- E-mail extensions have changed to "@jointcommission.org."
“These changes and the branding initiative underlying them are intended to symbolize and guide our ongoing commitment to achieve excellence in our daily work,” says Mary Cesare-Murphy, Ph.D., executive director, Behavioral Health Care Accreditation. “The changes also acknowledge our broadening scope of services and products.”
The changes have been in development for nearly a year. In 2006, The Joint Commission solicited feedback from many accredited organizations to assess their perception of The Joint Commission and obtain suggestions on how The Joint Commission could improve its approach to accreditation. In addition, The Joint Commission met with each program-specific advisory council and other key stakeholders to obtain feedback.
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The Joint Commission’s online Publicity Kit has been updated with the newly redesigned Gold Seal of Approval™. The free Publicity Kit offers tips and tactics to help organizations celebrate and promote their accreditation award. Some tips include:
- Download the Gold Seal of Approval and incorporate it into advertising, letterhead and stationery, business cards, client educational materials, and your organization’s website. There is no charge for accredited organizations to use the Gold Seal.
- Display your organization’s Certificate of Accreditation in a prominent location.
- Use the sample news release and send it to local media outlets.
- Notify any state or metropolitan provider association of which your organization is a member. Many of these associations publicize accreditation information in their newsletters.
- Notify the benefit manager at insurance carriers or behavioral health care plans whose clients use or might use your organization’s services.
- Include information on the benefits of accreditation in your organization’s newsletters and in presentations to staff, board members and community groups.
See the complete online Publicity Kit with the new Gold Seal.
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Organizations seeking Joint Commission accreditation in Florida can tap into the expertise of an on-site expert in their state, free of charge. Diana Murray, RN, MSN, an account executive located in Orlando, is available to answer all your questions about The Joint Commission survey and accreditation process.
“I provide education and support to organizations in Florida seeking Joint Commission behavioral health care accreditation,” Murray says. “This can be especially important for organizations that have never been accredited before.”
For instance, the State of Florida Agency for Healthcare Administration recently approved regulations requiring accreditation for providers in the Medicaid Prepaid Mental Health Plan. Magellan Behavioral Health Care was named one of the approved providers. “This means that if you are a subcontracted provider for Magellan, you must be accredited to participate in the Medicaid plan,” Murray explains. “However, if you’ve never been accredited before, the prospect can be rather daunting. I can come to your organization and help your staff develop a plan to become Joint Commission accredited.”
Previously, Murray was a Joint Commission surveyor in the home care and network accreditation programs. In addition, she was the owner of Health Care Enhancements, a quality improvement consulting firm. She can be reached at (407) 491-1547 or dmurray@jointcommission.org.
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Free educational conference calls are available for eligible Opioid Treatment Programs. The sessions take place monthly from 10:30 to noon, CST, and cover a variety of topics. The programs include:
- March 21: Achieving Compliance with Challenging Standards
- April 18: Applying the Tracer Methodology to the Periodic Performance Review
- May 16: Treatment Planning for OTP Patients with Co-occurring Illnesses
- June 13: How Treatment Planning is Reviewed during the Survey Process
- July 11: BHC Standards Review
- Aug. 15: 2007 National Patient Safety Goals
- Sept. 19: Continuous Accreditation Readiness
- Oct. 17: Standards for Recovery & Resiliency
- Nov. 21: Failure Mode Effect Analysis ― A Proactive Approach to Reducing Errors
A video and a book on applying the tracer methodology will be sent out by the end of March in preparation for the April audio conference call. In addition, OTPs will receive CDs of web-based courses covering Shared Visions-New Pathways and risk management by the end of February. Call Customer Service at (877) 223-6866 to register for the programs. If you have questions about the programs, contact Megan Marx, associate director, OTP Project, at mmarx@jointcommission.org.
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The Joint Commission conducts one-day unannounced surveys on a 5 percent random sample of organizations nine to 30 months following the accreditation date. During the survey, the surveyor assesses both fixed and variable components, or performance areas. The survey may lead to requirements for improvement and completion of evidence of standards compliance.
Variable components are specific to the organization being surveyed. In 2007, the fixed components of random unannounced surveys are the applicable National Patient Safety Goals and the three most important Priority Focus Areas for each accreditation program. This year, the fixed components for behavioral health care organizations are:
- Assessment and Care/Services
- Client safety
- Medication management
Questions about random unannounced surveys should be directed to Kevin Hickey, director, Management Support Unit, at khickey@jointcommission.org or by calling (630) 792-5872.
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Communication among providers of care and planning of care proved to be the most troublesome areas for behavioral health care organizations from January through July 2006. The Joint Commission collects data on compliance with Joint Commission standards and National Patient Safety Goals to identify trends and focus education on challenging requirements. Organizations can use this information to benchmark their performance and use the data to determine if the processes meet requirements. The top areas out of compliance were:
- 21%: Goal 2, Improve the effectiveness of communication among caregivers.
- 19%: PC.4.40, The behavioral health care organization develops a plan for care, treatment, and services that reflects the assessed needs, strengths and limitations.
- 18%: PC.2.110, A nutritional screening is done, and when indicated, an in-depth nutritional assessment is performed.
- 17%: Goal 8, Accurately and completely reconcile medications across the continuum of care.
- 7%: HR.4.10, There is a process for ensuring the competence of all practitioners permitted by law and the behavioral health care organization to practice independently.
- 12%: LD.3.90, The leaders develop and implement policies and procedures for care, treatment and services.
- 11%: IM.6.10, The behavioral health care organization has a complete and accurate clinical/case record for clients assessed, cared for, treated or served.
- 11%: MM.2.20, Medications are properly and safely stored.
- 10%: EC.4.10, The behavioral health care organization addresses emergency management.
- 8%: EC.1.10, The organization manages safety risks.
- 8%: EC.9.10, The behavioral health care organization monitors conditions in the environment.
For more information, visit Standards Frequently Asked Questions. If your question is not addressed, contact the Standards Interpretation Group through its online question form or by calling (630) 792-5900.
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Behavioral health care staff members attend meetings and conventions throughout the year. In 2007, we’ll be at:
- March 26-28, National Council for Community Behavioral Health Care, Las Vegas, Nev.
- April 20, Association for Behavioral Health Care of Southern California, Buena Park, Calif.
- April 29-May 1, National Association of Psychiatric Health Systems, Washington, D.C.
- May 6-9, National Association for Children’s Behavioral Health Care, Washington, D.C.
- May 21-24, U.S. Association for Psychosocial Rehabilitation, Orlando, Fla.
- July 8-11, State Associations of Addiction Services, Chicago, Ill.
- July 29-31, Association of Ambulatory Behavioral Health, Boston, Mass.
- Oct. 17-19, Alliance for Children & Family Services, Anaheim, Calif.
- Oct. 20-24, American Association for the Treatment of Opioid Dependence, San Diego, Calif.
- Oct. 24-27, American Association of Children’s Residential Centers, Orlando, Fla.
- Oct. 31-Nov. 3, Association for the Treatment of Sexual Abusers
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For information or to order products from Joint Commission Resources, Inc., go to www.jcrinc.com/Infomart.htm or call (877) 223-6866.
Education
Accreditation Essentials: Behavioral Health Care
This program provides basic training for any behavioral health care organization considering accreditation. It includes breakout sessions for addiction treatment programs, children and youth programs, and community mental health centers.
- April 26-27, Philadelphia, Pa.
- June 26-27, Atlanta, Ga.
Save the date!
Behavioral Health Care Update
- November 7, Phoenix, Ariz.
- December 11, Chicago, Ill.
4th Annual Joint Commission National Conference on Behavioral Health Care: Issues for Today, Actions for Tomorrow
- December 12-13, Chicago, Ill.
Publications
Accreditation Process Guide for Behavioral Health Care
Takes you step-by-step through the entire accreditation process, with practical, up-to-date information to help all levels of behavioral health care staff prepare for the on-site survey.
Order code: BHSP06SJ, $119
How to Meet the Most Challenging Joint Commission Requirements for Behavioral Health Care
Learn about the most common compliance challenges for behavioral health care organizations, and benefit from shared strategies and tips on meeting the requirements.
Order code: MCRBH-06, $75
A Practical Guide to Documentation in Behavioral Health Care
Your complete guide to good documentation practices that meet Joint Commission behavioral health care standards.
Order code: BH500SJ, $55
2007 National Patient Safety Goals for Behavioral Health Care
This laminated poster is an ideal way to communicate to staff what the goals require, and serves as a colorful reminder about incorporating safety into everyday activities.
Order code: NPSGBCLP07SJ, $35, for a set of 10
Cost-effective Performance Improvement in Behavioral Health Care
Order code: PIBHC50SJ, $50
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