I’m delighted to report that a well-respected advocate for the behavioral health care field, New York Commissioner of Mental Health Michael F. Hogan, Ph.D., has been appointed as the behavioral health care field representative to The Joint Commission’s Board (see article).
This appointment is important because it clearly demonstrates The Joint Commission’s commitment to the behavioral health care field, and it provides an opportunity for someone of Dr. Hogan’s stature to contribute on topics of interest to the behavioral health care field.
It is a great honor to have Dr. Hogan as an active participant on the Board of Commissioners and I anticipate his involvement will strengthen the relationship between The Joint Commission and the field.
For a look at current issues affecting behavioral health care organizations, consider attending the National Conference on Behavioral Health Care: Issues for Today, Actions for Tomorrow. This is the fourth year for this gathering of the most interesting movers, shakers, leaders and thinkers in our field. I hope you can join us for a lively dissection of current topics in behavioral health care. (See registration details.)
Mary Cesare-Murphy, Ph.D.
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New York Commissioner of Mental Health Michael F. Hogan, Ph.D., has been appointed as the non-voting behavioral health care field representative to the Board of Commissioners of The Joint Commission.
Prior to assuming responsibilities for the New York Office of Mental Health, Hogan served as director of the Ohio Department of Mental Health from 1991 to 2007. He was also chair of the President’s New Freedom Commission on Mental Health in 2001.
“Dr. Hogan’s expertise and in-depth experience in the mental health arena will enrich Board discussions on policy issues respecting behavioral health care,” says Dennis S. O'Leary, M.D., president, The Joint Commission. “This action underscores the commitment of The Joint Commission and its Board to all of those in the behavioral health care field who are in turn committed to serving this vulnerable population.”
“This is an honor, and a great opportunity for behavioral health,” says Hogan. “The Joint Commission’s action in creating this position reinforces that behavioral health is essential for overall health. I hope to serve our field well in representing our concerns about good care.”
The initial term for the Behavioral Health Care representative began in March and will extend through December 31, 2008.
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Merlin Wessels, associate director, Standards Interpretation Group, answers these Frequently Asked Questions about the Periodic Performance Review.
What is the PPR?
The PPR is a self-evaluation that gauges an organization’s compliance with accreditation participation requirements, National Patient Safety Goals, standards and Elements of Performance. If the organization finds areas out of compliance, it develops a Plan of Action. The organization will also identify Measures of Success for validating the resolution of the problem areas for those Elements of Performance which require a measure.
What are the benefits?
It makes organizations more aware of the requirements, so they can take appropriate action before the survey.
How often is it completed?
Once accredited, organizations are required to update and submit the PPR annually. The accreditation date is the due date.
Are there options for completing the PPR?
You can choose to do a full PPR with or without a follow-up call to SIG; or choose among three other options. Most behavioral health care organizations choose the full PPR with the follow up call. See a full description of the options.
How do I begin?
The PPR is available anytime on the Joint Commission Connect extranet. Once your organization has completed it, the information will be there next year. You don’t have to start from scratch every time.
What’s the best way to get it done?
Organizations usually divide the work among different staff members to conduct the assessment. Then they submit the completed PPR to The Joint Commission. After this, they can choose to have a conference call with SIG to discuss the findings. If they choose to have a phone call, we go over the POA for standards out of compliance and check their responses to each.
If the organization chooses not to have a call, Joint Commission staff review the PPR and notify the organization if there are problems, e.g., if they’ve set a compliance date too far out.
What are the common problems and misconceptions?
Organizations think that the PPR is punitive. It’s not. Surveyors do not have access to the PPR; however, they will ask about the MOS related to the findings of the POA, but they never see the actual PPR.
In addition, there are organizations that score standards that don’t apply and organizations which neglect to score standards that do apply. It’s important to use the Standards Applicability Process in the front of the manual to see what standards, rationales and Elements of Performance apply to your organization’s setting, programs, services and populations.
Tips for making the most of the follow up phone call?
- Be prepared, have questions ready that you want addressed.
- View the time as a consultation opportunity. The focus does not have to be exclusively on the noncompliance areas. We can help you brainstorm and give you feedback on how other organizations meet the standards.
For more information, see the Facts about the Periodic Performance Review.
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A restraint and seclusion standard that applies only to organizations accredited under the Comprehensive Accreditation Manual for Hospitals has been revised to align with Centers for Medicare & Medicaid Services’ rules. Effective immediately, Standard PC.12.90 ― which addresses the requirement for in-person evaluation of a patient when restraint or seclusion is initiated ― has been revised to align with the CMS Final Rule for Patient Rights. Issued in December 2006, the rule allows a registered nurse or physician assistant to evaluate a patient within one hour of the initiation of restraint or seclusion, provided that such practitioner has been trained in accordance with CMS requirements and that this practitioner consults with the attending physician or a licensed independent practitioner as soon thereafter as possible.
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Beginning July 1, 2007, unannounced surveys can be conducted anywhere from 18 months to 39 months from your last survey. If you were surveyed in January 2006, your next unannounced survey could come as early as July 2007. Check on The Joint Commission Connect extranet by 7:30 a.m., local time, for information about Joint Commission scheduled events.
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The Joint Commission Connect extranet site ― the Joint Commission’s main electronic communication link with its customers ― will soon have a new look. To see what’s in store, go to the current extranet site, click on “What’s New” and see a sample screen shot and read about its features. One of the new features is that you will be able to directly access the site by going to http://www.jointcommissionconnect.org/. Other features include:
- Enhanced security controls to enable organizations to apply security settings for individuals. An organization will be able to allow certain individuals to have access to all of the accreditation tools on the site, or it can limit access to other tools, for example, allow access only to the application for accreditation.
- A “What’s Due” section that provides an at-a-glance display of accreditation tasks, such as Evidence of Standards Compliance, Measures of Success, the Periodic Performance Review and the application for accreditation.
- A “New Reports” section that provides an at-a-glance display of recently posted organization reports, such as the accreditation report.
- For corporate and multi-organization systems, a drop down menu list will enable the user to switch from one organization site to another.
- A “Quicklink” to update extranet contacts and apply security settings.
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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:
- July 11: BHC Standards Review
- Aug. 15: 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
Call Customer Service at (877) 223-6866 to register for the programs. If you have questions, contact Megan Marx, associate director, OTP Project, at mmarx@jointcommission.org.
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Behavioral health care staff members attend meetings and conventions throughout the year. In 2007, we’ll be at:
- 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, CA..
- Oct. 20-24, American Association for the Treatment of Opioid Dependence, San Diego, CA..
- Oct. 24-27, American Association of Children’s Residential Centers, Orlando, FL..
- 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
Save the date!
4th Annual Joint Commission National Conference on Behavioral Health Care: Issues for Today, Actions for Tomorrow
- December 12-13, Chicago, Ill.
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.
Publications
NEW! Issues in Human Resources for Behavioral Health Care
Presents practical explanations and guidance to the HR standards in the Comprehensive Accreditation Manual for Behavioral Health Care.
Order code: HRBHC05SJ, $75
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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