The behavioral health field has led the rest of medicine into an accreditation process that is based on the experience of the person receiving the care, according to Mary Cesare-Murphy, Ph.D., executive director of Behavioral Health Care Accreditation for the Joint Commission.
Why is behavioral health in the lead? Because there is something special about the field, she told Behavioral Healthcare Magazine in a recent interview. “They are true believers,” she said. “Throughout my tenure, the behavioral health field—and I mean this in the broadest sense of mental health, substance abuse, and developmental disabilities—has had an approach to accreditation that has been driven by wanting to constantly improve the care, treatment, and services they provide.”
While other healthcare providers subject to accreditation are motivated primarily by regulatory and payment concerns, behavioral health providers are “internally motivated,” said Murphy.
While these organizations want the secondary gains that come with accreditation, they also want the process to make them better at what they’re doing, she said. “This has been true throughout my career. So we have gotten better over the last 20 years at being helpful to them.” Thus, the Joint Commission’s accreditation process, which started for the field in 1991, now includes many value-added tools that organizations can use for improvement, she said. She added that accredited organizations also can use Joint Commission’s reach to learn more about promising practices of other accredited sites.
But perhaps the most radical transformation over the course of Dr. Cesare-Murphy’s tenure is the accreditation survey itself. When she started out as an intermittent surveyor, she recalled that the original surveys were based completely on documentation. “Today we use the tracer methodology, and look at services from the perspective of the recipient. Is it centered on the needs of the person and those of the family? Are the services fulfilling their expectations?”
Tracer methodology is an evaluation method in which surveyors select a patient, resident, or client and then use that individual’s record as a roadmap to move through the organization. Along the way, surveyors evaluate the organization’s compliance with selected standards and its systems for providing care and services.
Surveyors retrace the specific care processes that an individual experienced by observing and talking to staff in the areas or functions where the individual received care. As surveyors follow the course of treatment for a patient, resident, or client, they also assess the health care organization’s compliance with Joint Commission standards. The compliance assessment is conducted as surveyors review the organization’s systems for delivering safe, quality health care.
Sea-change on seclusion and restraint
Asked for a specific issue that marked the move toward patient-centered accreditation, Dr. Cesare-Murphy pointed to the focus on reducing restraint and seclusion practices within the mental health field. “This is strictly my opinion, but after the expose by the Hartford Courant [“Deadly Restraint,” 1998], the Joint Commission, including the board of commissioners, took this issue very seriously,” she said. “We conducted public hearings across the country. We listened to people who had been in restraints. We listened to families.”
The voices of consumers and families, who decried the abuse of restraint and seclusion, began to turn the tide within the Joint Commission. A series of public hearings, which Dr. Cesare-Murphy attended, convinced her that consumer input was central to an effective behavioral health accreditation process. “I was one of a few staff members who were intimately involved” with the restraint and seclusion hearings, she said. “As a psychologist it was also eye-opening for me.”
The hearings marked a turning point at the Joint Commission. From then on, there was an appreciation of the “value of the input and perspective of the people who receive services,” she said. “It changed the direction of all of our processes, because it changed how people thought about care.” The new restraint and seclusion standards came out in 2000.
From that sea-change in perspective, many other and more gradual changes followed. Behavioral health took note of a growing recovery movement, while awareness of the emerging role of peers and peer support services grew.
Recognizing treatment beyond the hospital
As recently as 20 years ago, the Joint Commission accredited psychiatric hospitals, as well as residential and community-based services, under the same set of standards. “It very quickly became obvious that these are two different settings, and that we needed a separate manual for things other than hospitals, that are based in the community or in the home,” said Dr. Cesare-Murphy. She notes that the Joint Commission created these standards prior to the Supreme Court’s Olmstead ruling. “Not to give us too much credit, but the Joint Commission was ahead of the curve” in recognizing that many treatment services occurred outside of hospitals. At first, home services weren’t included, though they are now.