Person to Person - Issue 1, 2023
Person to Person is published by The Joint Commission’s Department of Corporate Communications.
March 28, 2023
The Joint Commission has eliminated nine standards and revised one other in its Behavioral Health Care and Human Services Accreditation Program to streamline requirements and make them as efficient and impactful on patient safety, quality and equity as possible.
The reduction is the result of The Joint Commission’s comprehensive review that was announced in September 2022. These changes were part of the first tranche of standards deletions and revisions that went into effect on Jan. 1. In total, The Joint Commission eliminated 168 standards (14%) and revised 14 other standards across its accreditation programs.
The Joint Commission reviewed all its “above-and-beyond” requirements – those that go beyond regulatory requirements of the Centers for Medicare & Medicaid Services (CMS) Conditions of Participation (CoPs) and are not on crosswalks to the CoPs. Specifically, The Joint Commission reviewed each standard to answer:
- Does the requirement still address an important quality and safety issue?
- Is the requirement redundant?
- Are the time and resources needed to comply with the requirement commensurate with the estimated benefit to patient care and health outcomes?
In addition to a direct review of each standard, The Joint Commission conducted quantitative analyses of scoring patterns and tested for redundancy. Where necessary, it also led literature and field reviews and engaged experts within the field.
CMS approved the recommended discontinued standards after confirming they do not diminish any CMS regulatory requirements. Importantly, a second tranche of standards is under consideration for elimination or revision, and a second announcement of burden reduction is anticipated in approximately six months.
“The standards reduction will help streamline Joint Commission requirements, as well as provide some much-needed relief to healthcare professionals and organizations as they continue to recover from the pandemic,” said Jonathan B. Perlin, MD, PhD, MSHA, MACP, FACMI, president and chief executive officer, The Joint Commission. “Our goal is to eliminate any standard that no longer adds value. We want to have fewer, more meaningful requirements that best support safer, higher-quality and more equitable health outcomes.”
March 28, 2023
Effective July 1, 2023, Leadership (LD) Standard LD.04.03.08 — which addresses healthcare disparities as a quality and safety priority — will be elevated to a new National Patient Safety Goal® (NPSG®) for behavioral healthcare and human services organizations that provide any of the following:
- Addictions services
- Eating disorders treatment
- Intellectual disabilities/developmental delays
- Mental health services
- Primary physical healthcare
This change is being made to increase the focus on improving healthcare equity versus reducing healthcare disparities — but the requirements for accredited organizations are not changing. The intent behind the standard and associated elements of performance remains the same; however, they are now stated as NPSG Goal 16. Organizations will still be required to do the following:
- Identify an individual to lead activities to improve healthcare equity.
- Assess clients’ health-related social needs.
- Analyze quality and safety data to identify disparities.
- Develop an action plan to improve healthcare equity.
- Act when the organization does not meet the goals in its action plan.
- Inform key stakeholders about progress to improve healthcare equity.
Following the implementation of NPSG Goal 16, Standard LD.04.03.08 will be deleted. Additionally, the resources in The Joint Commission’s Health Care Equity Accreditation Standards and Resource Center will continue to apply to the new NPSG. The resources contain valuable information for organizations working toward compliance with the healthcare equity requirements.
March 28, 2023
The Joint Commission has approved 81 new requirements for behavioral healthcare and human services organizations that select the Certified Community Behavioral Health Clinic (CCBHC) service on their electronic application (E-App). The new requirements go into effect on July 1.
CCBHCs provide coordinated, comprehensive access to a variety of behavioral health and primary physical health services in accordance with the Substance Abuse and Mental Health Services Administration (SAMHSA) criteria. CCBHCs are required to serve anyone who requests care for mental health or substance use, regardless of their ability to pay, place of residence, or age.
Organizations that select the CCBHC service on their application will have their compliance with these new standards assessed during the organization’s accreditation survey like other programs and services. New, however, is that the CCBHC designation will be shown on their Quality Report, and CCBHC is now a searchable service category within Quality Check®.
These new requirements align with the current SAMHSA criteria for CCBHCs. Accredited organizations that meet Joint Commission CCBHC requirements will be better prepared to meet the national expectations for a CCBHC program and better able to validate the quality and safety of the care, treatment, and services provided by the CCBHC.
“The Joint Commission now provides state authorities and payors with a new way to confirm that CCBHCs are truly meeting all SAMHSA requirements,” said Melinda Lehman, Executive Director, Behavioral Healthcare and Human Services, The Joint Commission. “And now with Joint Commission Accreditation, there will be — for the first time — validation of the quality and safety of the programs and services being provided to the individuals these clinics serve.”
Recently, SAMHSA published updates to its CCBHC requirements. The Joint Commission will update its CCBHC requirements in return to match SAMHSA’s July 1, 2024 effective date.
March 28, 2023
The Joint Commission has appointed Melinda Lehman, MBA, as the new executive director of its Behavioral Healthcare and Human Services (BHC) Accreditation Program. Lehman is a healthcare executive with more than 25 years of experience in business development and marketing.
As executive director, Lehman will be responsible for developing and executing strategic business plans to expand the BHC Program, including driving product development to meet the needs of current and prospective customers. Additionally, Lehman will oversee marketing strategies and support the development of BHC standards, education programs and other accreditation-related resources.
Previously, Lehman spent 15 years in The Joint Commission’s Marketing Department, most recently as Associate Director of Marketing for the program. During that time, she contributed to the BHC Program doubling in size from approximately 1,800 accredited organizations to nearly 4,000. Prior to The Joint Commission, Lehman worked in pharmaceutical sales and at several healthcare advertising and marketing agencies in Chicago.
“Melinda has proven experience in growing The Joint Commission’s BHC Program and is a strong fit for this leadership role,” said Brian Enochs, JD, Executive Vice President, Business Development and Marketing. “As the demand for behavioral healthcare services continue to increase, I look forward to Melinda’s expertise in identifying new opportunities to grow, while also continuing to focus on patient safety and quality improvement for individuals served.”
Lehman graduated from the University of Michigan, Ann Arbor, Michigan, with a bachelor’s degree in communications. She also received her Master of Business Administration from DePaul University, Chicago. She is a Certified Lean Six Sigma Green Belt.
Launched in 1969, The Joint Commission began accrediting healthcare organizations with programs/services for persons with intellectual and developmental disabilities. The program expanded in 1972 to include organizations providing mental health and addiction services.
Learn more about BHC Accreditation.
March 28, 2023
A new search page is now available to easily find Joint Commission-accredited organizations that provide substance use disorder (SUD) treatment and to view the organizations’ levels of care.
Whether it is individuals seeking treatment, providers referring individuals for care, or state authorities or payors seeking information, users can search by organization name or location and filter by:
- Medication availability
- Services offered, specific to the levels of care provided
- State the provider is located
This page provides greater visibility for accredited providers with key stakeholders, including those seeking care, and improves the clarity of information available about the types of services and levels of care they provide. The search page currently displays only accredited SUD providers that have updated their application with their levels of care. If you do not see your organization listed and feel it should be, please update your application or contact your account executive.
View the search page.
March 28, 2023
It is never too early to ensure your spot at the 2023 Behavioral Health Care and Human Services Conference. The annual conference is scheduled for Oct. 17-18 at the Crowne Plaza Chicago O’Hare, 5440 N. River Road in Rosemont, Illinois.
Those who attend will take part in sessions on the hottest behavioral healthcare topics and gain a better understanding of upcoming changes at The Joint Commission that will be helpful to their organizations maintaining compliance in 2024. Attendees will have two tracks to choose from:
- Track A: Designated for organizations accredited under the Comprehensive Accreditation Manual for Behavioral Health Care and Human Services.
- Track B: Designated for organizations accredited under the Comprehensive Accreditation Manual for Hospitals.
March 28, 2023
The popular PolicySource subscription is now available as an annual e-book, including for its Behavioral Health Care and Human Services version.
The e-book includes the same great content as the online subscription version, including all existing policies and procedures (P&Ps), tools, and other resources. It also features:
- New and updated P&Ps that are easy to identify, with redline changes marked in existing P&Ps.
- P&Ps that correlate to Joint Commission requirements that went into effect on Jan. 1.
Purchase a subscription to PolicySource.