I’m in the middle of a small remodeling project that has been going on for far too long. Living with the construction is uncomfortable and bothersome. I look back to the time before I started and think, “Was it really so bad?” Some of the old problems have been fixed, and others are in the works. It can be frustrating, but I know the improvements will far outweigh any problems I’m having with the transition period.
The Joint Commission’s Standard Improvement Initiative is a major remodeling project. We are taking the accreditation manual apart and fixing the inconsistencies, updating the wording, renumbering and reorganizing it. Some of the chapters have been updated and good changes were made. However, we’re still in the midst of revising, so 2009 will be a transition year. The article on this page provides the specifics on what to expect in the coming months. Just keep in mind that the transition won’t last forever and the accreditation manual will be much improved in 2010.
In the meantime, the E-dition of the manual is coming to a computer near you. I’m eager to hear what you think about this new option. Send me your thoughts at mcesaremurphy@jointcommission.org and we’ll share some of your experiences in an upcoming issue.
Mary Cesare-Murphy, Ph.D.
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January 1, 2009, will ring in more than a new year for accredited behavioral health care organizations. As a result of the Standards Improvement Initiative, some of the SII improvements will be implemented in the 2009 standards manual, with the majority of the improvements going live in 2010. The changes include newly revised standards chapters, a new scoring process and an E-dition (electronic version) of the accreditation manual. Here’s an overview of what you can expect.
Extensive work is ongoing to the 2010 manual to revise and reorganize the standards to make them clearer, eliminate redundancies and create a simpler, more logical order. In 2009, the Comprehensive Accreditation Manual for Behavioral Health Care contains revisions to the Accreditation Participation Requirements, National Patient Safety Goals, Leadership and Life Safety chapters. In addition:
- The standards in the new chapters have a different numbering system to enable electronic enhancements.
- The other chapters retain the previous numbering system until 2010, when they will be re-numbered.
- Icons have been added to provide a guide to the requirements (see icon key below).
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The new scoring and decision processes, effective January 1, 2009, focus on how critical an issue is to client care or safety, as identified by noncompliant standards. The more critical the issue, the shorter the time frame that an organization has to address it.
Following are highlights of the revisions. For a complete description of the changes, see the December 2008 edition of Joint Commission Perspectives or the introduction to the 2009 Accreditation Manual for Behavioral Health Care.
- Decisions of Conditional Accreditation and Preliminary Denial of Accreditation will be driven by those standards that have the most direct impact on patient care or safety.
- There is no longer a supplemental section in the Accreditation Report. All findings of less than full compliance require resolution via submission of Evidence of Standards Compliance.
- The use of “thresholds” to determine Conditional Accreditation and Preliminary Denial of Accreditation has been revised. Program-specific thresholds will serve only as “screens” for identifying organizations whose survey findings require more extensive review by Joint Commission Central Office staff. The screens are based on the number of Direct Impact standards (see icon key) that are noncompliant.
- As requested by the field, Category B elements of performance have been re-categorized to either A or C. Category A reflects presence, absence or consistency and Category C is frequency based.
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Icons will be used to identify the scoring category, measure of success designation, whether documentation is needed, and the criticality of certain elements of performance (EPs). The icons that will be used in the manuals and their meanings are defined below. An icon key is provided at the bottom of each requirement page. EPs that do not have a “2”or “3” are considered Indirect Impact requirements (level 4). No EP is tagged as an Immediate Threat to Life requirement; instead, an Immediate Threat to Life situation is usually the result of noncompliance with a combination of EPs at any or all of the Situational Decision Rules, Direct Impact, and Indirect Impact levels.
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In response to feedback from accredited organizations, The Joint Commission has launched the E-dition, an electronic, searchable version of the accreditation manuals. All organizations receive one complimentary single-user license E-dition. If an organization is accredited under more than one accreditation manual, it will receive one complimentary single-user license E-dition for each manual it is accredited under. This single-user license allows anyone in the organization to access E-dition on a one person at-a-time basis. The E-dition may be upgraded by purchasing a multi-use site license or additional single-user licenses.
Between November 14 and 21, accredited organizations received an e-mail from Joint Commission Resources (JCR) containing a password with a link for accessing E-dition. The e-mail was sent to the organization’s primary accreditation and Periodic Performance Review (PPR) contacts. Additionally, a link to the E-dition is posted on every organization’s Joint Commission Connect extranet. This link will be a single-user guest link specific to each organization and will provide staff with the convenience of accessing E-dition without providing a login and password. In addition to the standards, the 2009 E-dition contains many new features and navigational tools such as:
- Always current. Contains the same changes published in Perspectives.
- Search ability. Provides keyword search across all standards, rationales and EPs to help users quickly find what they’re looking for.
- Three clicks to most standards. E-dition puts The Joint Commission standards and National Patient Safety Goals at your fingertips.
- Related links. Links to Joint Commission FAQs, sentinel event communications and other valuable information to related chapters of standards.
For more information about the E-dition, visit the JCR website at www.jcrinc.com/e-dition, or contact a JCR customer service representative at (877) 223-6866. If you need help accessing the E-dition, contact JCR E-dition Tech Support at (630) 792-5420.
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The PPR will be off-line from December 1, 2008 until January 1, 2009 while the new standards and scoring methods are loaded into the system. Therefore, organizations with PPR due dates from October 1 through December 31, 2008 are not required to submit a 2008 PPR. For more information see the October 2008 issue of Joint Commission Perspectives.
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The Opioid Treatment Program stand-alone chapter in the 2009 Comprehensive Accreditation Manual for Behavioral Health has been updated to reflect the changes made to the federal government’s Guidelines for the Accreditation of Opioid Treatment Programs. Unfortunately, other OTP references in the functional chapters of the manual were not updated to reflect the changes made in the OTP chapter. OTPs must be in compliance with the requirements in the OTP chapter. This oversight will be corrected in the next edition. If you have questions about which standards apply to your OTP, contact Megan Marx, OTP associate director, (630) 792-6195 or mmarx@jointcommission.org.
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The Joint Commission is asking for your comments on the standards and the National Patient Safety Goals.
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BHC News, the free quarterly newsletter, is chock full of the latest news and information from the Behavioral Health Care Accreditation Program. Be the first on the block to receive the newsletter by signing up to receive it automatically at www.jointcommission.org/Library/Newsletters/list_serve.htm.
The National Resource Center on Psychiatric Advance Directives offers consumers and health care professionals help in drafting and using psychiatric advance directives. Psychiatric advance directives may be used to document a competent person’s specific instructions or preferences regarding future mental health treatment. Almost all states permit some form of legal advance directive (AD) for health care, which can be used to direct at least some forms of psychiatric treatment. For more information, go to the Web site at http://www.nrc-pad.org/.
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Merlin Wessels, L.C.S.W., A.C.S.W., associate director
Standards Interpretation
Q: Do the restraint standards apply to physical holds?
A: Physical holds are restraints that are applied to minors, children and youth under the age of 18 and last no longer than 30 minutes. The two restraint standards that apply to physical holds are:
- PC 12.30: Staff are trained and competent to minimize the use of restraint and seclusion and, when use is indicated, to use restraint or seclusion safely. The organization should educate their staff about minimizing the use of physical holds and assess the competence of the staff to use them safely. The surveyor will be checking to see that the organization demonstrates competence in the various skills identified within the standard. Elements of Performance 11 and EP 12, which address the viewpoints of clients, should be included in the training, when possible. It’s important to be sensitive to the clients in these positions.
- PC 12.140: Clients in restraint or seclusion are monitored. Whenever someone is placed in a physical hold, The Joint Commission requires that another individual not directly involved in the hold be an observer. For example, if two individuals are involved in a physical hold, a third person is required to be an observer. The purpose of this requirement is to ensure the safety of the person in the physical hold.
If the physical hold exceeds 30 minutes, then all of the restraint standards apply.
For more information, contact the Standards Interpretation Group at (630) 792-5900 or use the online form at http://www.jointcommission.org/Standards/OnlineQuestionForm.
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Education
Joint Commission Accreditation Summit
April 28-29, 2009, Rosemont, Ill.
Organizations will have a dialogue with Joint Commission executives and program leaders on significant accreditation topics and receive the latest updates on Joint Commission standards and the accreditation process. The comprehensive curriculum includes plenary lectures and breakout sessions that address topics of interest.
Pre-conference Primer for Behavioral Health Care
April 27, 2009
Rosemont, Ill.
Offers information for those new to the accreditation process or those who need to get basic questions answered before the Accreditation Summit.
Save the date!
Annual Behavioral Health Care Conference and Pre-conference
Nov. 16-18, 2009, Chicago, Ill.
Publications
2009 Comprehensive Accreditation Manual for Behavioral Health Care
Contains the standards, rationales, elements of performance, scoring, decision rules, accreditation participation requirements, National Patient Safety Goals, and policies and procedures for the behavioral health care accreditation field.
Order code: CBHC09, $265
2009 Accreditation Process Guide for Behavioral Health Care
This easy-to-use, spiral-bound edition features updated self-assessment checklist questions for all elements of performance, including new chapters on Life Safety and Leadership. And, new scoring information is included for all self-assessment questions.
Order code: BHSP09, $119
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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