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Refining requirements for behavioral healthcare quality

February 1, 2007
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The Joint Commission introduces behavioral health-specific tracers and other accreditation enhancements

While accreditation standards and survey processes for behavioral healthcare organizations accredited by the Joint Commission have not changed significantly, several notable refinements take effect for 2007.

Behavioral Health-Specific Tracers

To better address the unique characteristics and relevant issues of each accredited organization, Joint Commission behavioral healthcare surveyors will have a wider range of behavioral health-specific tracers during surveys. The tracer methodology is a significant component of the accreditation process, providing a framework for Joint Commission surveyors to assess standards compliance and patient safety during on-site surveys. The new setting-specific tracers were identified through a review of expert literature, research, input from the field, and advisory group suggestions. The tracers are:

Continuity of foster/therapeutic foster care.The objectives of this tracer are to evaluate the effectiveness of the foster/therapeutic foster care agency processes surrounding placement of children and identify process- and possibly system-level issues contributing to multiple placements. This tracer is applicable to foster/therapeutic foster care settings (in the presence of multiple placements within the same foster care agency). This tracer only will be used in agencies responsible for foster care placement decisions.

Elopement.Surveyors will evaluate the effectiveness of processes to prevent elopement, therefore enhancing safety and identifying process- and possibly system-level issues contributing to successful elopements. This tracer is applicable to a wide range of settings in which elopement is an issue.

Suicide prevention.This tracer examines the effectiveness of the organization's suicide prevention strategy and identifies process- and possibly system-level issues contributing to suicide attempts. This tracer is applicable to 24-hour settings such as residential care (when organizations have experienced suicide, suicide attempts, or a series of near misses).

Violence.The objectives of this tracer are to evaluate the effectiveness of the organization's process to control violence and ensure the safety of others, and identify process- and possibly system-level issues contributing to violent behavior. This tracer is applicable to all behavioral health settings when surveyors identify concerns related to violent behavior.

The Joint Commission plans to continue the development of additional behavioral health-specific tracers. Ultimately, a library of survey process activities will be available, which will allow surveyors to mix and match activities based on the unique characteristics of each organization.

Changes to National Patient Safety Goals

Goal 8.This previously existing goal requires behavioral health organizations to accurately and completely reconcile medications across the continuum of care. New language has been added to Requirement 8B. Specifically, the requirement now includes language that “the complete list of medications is also provided to the client on discharge from the facility.” This addition is a clarification; this expectation has been implicit in the goal and the discharge planning standards.

Goal 13.This new goal applicable to behavioral health organizations encourages clients’ active involvement in their own care as a client safety strategy. This concept is a component of the Provision of Care Chapter and the standards for Services that Support Recovery and Resiliency, so it is already a familiar concept to behavioral healthcare organizations.

Goal 13's Requirement 13A requires organizations to define and communicate the means for clients and their families to report concerns about safety and encourage them to do so. Requirement 13A's Implementation Expectation is that clients and families are educated on methods available to report concerns related to care, treatment, services, and client safety issues.

Goal 15.This other new goal applicable to behavioral health organizations requires them to identify safety risks inherent in its client population. Suicide consistently has been a red flag in the Joint Commission's sentinel event database. The important consideration when complying with this goal is for organizations to screen clients, identify those who are at risk for suicide, and provide resources to those individuals. This goal, which is similar to the expectations for Standard 2.10.

Goal 15's Requirement 15A requires organizations to identify clients at risk for suicide. The Implementation Expectations for Requirement 15A are that:

  1. 1. the risk assessment includes identification of specific factors and features that may increase or decrease risk for suicide;

  2. 2. the client's immediate safety needs and most appropriate setting for treatment are addressed; and

  3. 3. the organization provides information, such as a crisis hotline to individuals and their family members, for crisis situations.

New Automated Tools

New reporting tools for sentinel events and complaint reporting are now available on the Joint Commission's secure Extranet site. These online tools for complaint responses, self-reporting a sentinel event, submitting root cause analyses and action plans, and sentinel event measures of success must be used by behavioral healthcare organizations instead of mailing or faxing this information to the Joint Commission.