The Joint Commission collects data on organizations’ compliance with standards, National Patient Safety Goals (NPSGs), and Accreditation and Certification Participation Requirements to identify trends and focus education on challenging requirements.
The Top 5 Behavioral Health Care and Human Services (BHC) requirements identified most frequently as “not compliant” during surveys and reviews from Jan. 1 through Dec. 31, 2021, were under NPSG.15.01.01: Reduce the risk for suicide. In order of greatest to least percentage of noncompliance, they were:
- Element of Performance (EP) 2: Screen all individuals served for suicidal ideation using a validated screening tool.
- EP 1: The organization conducts an environmental risk assessment that identifies features in the physical environment that could be used to attempt suicide and takes necessary action to minimize the risk(s) (for example, removal of anchor points, door hinges, and hooks that can be used for hanging).
- EP 5: Follow written policies and procedures addressing the care of individuals served identified as at risk for suicide. At a minimum, these should include the following:
- Training and competence assessment of staff who care for individuals served at risk for suicide.
- Guidelines for reassessment.
- Monitoring individuals served who are at high risk for suicide.
- EP 3: Use an evidence-based process to conduct a suicide assessment of individuals served who have screened positive for suicidal ideation. The assessment directly asks about suicidal ideation, plan, intent, suicidal or self-harm behaviors, risk factors, and protective factors.
- EP 4: Document individuals’ overall risk for suicide and the plan to mitigate the risk for suicide.
For more information, see the April 2022 issue of Perspectives or the Standards Frequently Asked Questions. The Joint Commission also has a Suicide Prevention Portal with resources for organizations seeking to be in compliance with NPSG.15.01.01.
Effective Jan. 1, 2023, new and revised requirements to reduce healthcare disparities will apply to Joint Commission-accredited behavioral healthcare and human services (BHC) organizations.
A new R3 Report — Issue 36: New Requirements to Reduce Health Care Disparities — delves into the rationale and references behind the new BHC requirements, which include:
- A new standard in the Leadership (LD) chapter — Standard LD.04.03.08 — with six new elements of performance (EPs) developed to address healthcare disparities as a quality and safety priority. It will apply to BHC organizations providing “Addictions Services,” “Eating Disorders Treatment,” “Intellectual Disabilities/Developmental Delays,” “Mental Health Services,” and “Primary Physical Health Care” services.
- A revision to the Record of Care, Treatment, and Services (RC) requirement to collect patient race and ethnicity information. (Standard RC.02.01.01, EP 26)
- A Rights and Responsibilities of the Individual (RI) requirement prohibiting discrimination. (Standard RI.01.01.01, EP 29)
Read the R3 Report.
Did you miss the one-hour webinar discussing steps community-based behavioral health care and human services agencies can take to help reduce suicides? The webinar is now available on-demand and can help viewers learn how these concepts are supported by Joint Commission accreditation requirements.
View the webinar.
Diagnostic overshadowing — defined as the attribution of symptoms to an existing diagnosis rather than a potential co-morbid condition — is a risk to patient safety. Extensive evidence shows that diagnostic overshadowing exists within the interactions of clinicians with patients of all ages who have physical disabilities or previous diagnoses including autism, mobility disabilities, and neurological deficits, as well as patients with conditions or characteristics such as, but not limited to, LGBTQ identifications, history of substance abuse, low health literacy, and obesity.
A new issue of Sentinel Event Alert — “Issue 65: Diagnostic overshadowing among groups experiencing health disparities” — details this issue and includes a patient’s experience told from that patient’s point of view.
Read the Sentinel Event Alert.
The Joint Commission is concerned about the well-being of our nation’s healthcare workers. As U.S. Surgeon General Vivek Murthy said, “The nation’s health depends on the well-being of our health workforce.” To that point, The Joint Commission has launched the Healthcare Workforce Safety and Well-Being Resources website.
The webpage provides links to materials developed by The Joint Commission and key healthcare-related organizations, such as the National Academy of Medicine, government agencies (including the Office of the Surgeon General and the Centers for Disease Control and Prevention National Institute for Occupational Safety and Health). The content focuses on organization and system-level resources.
The Joint Commission hopes healthcare workers find the information useful and welcomes suggestions for improvement.
Have you made your reservation yet? The annual Behavioral Health Care and Human Services (BHC) Conference is scheduled Sept. 29-30. The event — which will offer in-person or virtual attendance — will take place at the Crowne Plaza Chicago O’Hare, 5440 N. River Road in Rosemont, Illinois.
The conference will feature programs on the hottest topics in BHC and will offer attendees a better understanding of upcoming changes at The Joint Commission. Participants will have two tracks to choose from during the conference:
- 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.
An online toolkit from The Joint Commission — the Readiness Roadmap — will help organizations better locate available resources for survey based on where they are in the accreditation process.
The toolkit is accessible on The Joint Commission’s Connect® extranet site under the Resources and Tools tab. It features resources sorted by categories, including:
- Checklists
- Crosswalks
- Webinars
- Videos
For more information or questions, organizations should reach out to their designated account executive.
A new book available from Joint Commission Resources (JCR) focuses on The Joint Commission’s Emergency Management (EM) standards chapter for all healthcare settings. “Emergency Management in Health Care: An All-Hazards Approach, 5th Edition” aims to help in identifying hazard vulnerabilities and preparing for any type of emergency.
Highlights of the book include:
- Focused information and resources for behavioral health and human services providers.
- More than 30 customizable, downloadable tools to assist with emergency preparedness and compliance with the EM standards.
- Lessons learned from the COVID-19 pandemic.
- EM education and training, as well as testing and evaluating the components of an organization’s EM program, such as:
- Hazard vulnerability analysis (HVA)
- Continuity of operations plan (COOP)
- Emergency exercises or responses to real emergencies
Purchase the book.
Resources dedicated solely to infection prevention and control (IPC) in nonacute care settings are limited. A new book from Joint Commission Resources (JCR) — “Infection Prevention and Control in Nonacute Care Settings” — focuses on IPC challenges in behavioral health care and human services.
The book outlines Joint Commission IPC requirements for nonacute care settings and focuses on where organizations struggle, providing timely, accessible solutions. Key topics include:
- Developing a robust IPC program.
- Identifying, assessing, and mitigating IPC risks in the nonacute care setting.
- Cleaning, disinfecting, and sterilizing medical equipment and other tools.
- Handling infectious disease emergencies.
Joint Commission Resources (JCR) has updated all six modules of PolicySource. These latest updates to the sample policies and procedures (P&Ps) resource reflect the July 1 standards changes, including a medication reconciliation policy and environmental safety and security risk identification procedures for behavioral health care and human services organizations.