Conquering Challenging Standards · 2019. 9. 16. · Behavioral Health Care Program ⎻Accrediting...

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© 2018 The Joint Commission. All Rights Reserved.

Conquering Challenging Standards

August 13th 2019

Darrell Anderson

Business Manager, Behavioral Health Care

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Agenda

⎻Background

⎻ The Accreditation Requirements

⎻ Top 10 Most-cited Standards from recent surveys

⎻Assistance and Resources

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Background

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⎻ Ambulatory Health Care

⎻ Behavioral Health Care

⎻ Home Care & Hospice Services

⎻ Hospital

⎻ Laboratory Services

⎻ Nursing Care Centers

About The Joint Commission

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⎻Nationally and Internationally known

⎻Over 21,000 Health Care Organizations Accredited

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Mission and Vision

̶ Our MissionTo continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel, in providing safe and effective care of the highest quality and value.

̶ Our VisionAll people experience the safest, highest quality, best-value health care across all settings.

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Behavioral Health Care Program

⎻Accrediting Behavioral Health Care organizations for 50 years – since 1969

⎻Based in Oakbrook, IL (Chicago area)

⎻Experienced in accrediting a broad range of settings/services for organizations large & small

⎻3200+ Accredited Behavioral Health Organizations

• 38% not-for-profit

• 40% for profit

• Over 11,200 sites of care

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Behavioral Health CareAccreditation Requirements

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⎻ Available electronically or in print manual form

⎻ Electronic version free to organization after applying for accreditation

⎻ 90-day free trial available for organizations considering accreditation

− Contact us via email on last slide or sign up at www.jointcommission.org/BHCS under

“standards”

⎻ Print manual available at www.jcrinc.com

http://www.jointcommission.org/BHCS

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Behavioral Health CareStandards Manual Chapters

⎻ Care, Treatment & Services

⎻ Emergency Management

⎻ Environment of Care

⎻ Human Resource Management

⎻ Infection Control

⎻ Information Management

⎻ Leadership

⎻ Life Safety

⎻ Medication Management

⎻ National Safety Goals

⎻ Performance Improvement

⎻ Record of Care, Treatment, or Services

⎻ Rights of the Individual

⎻ Waived Testing

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Note: The specific programs and services your organization provides determines which standards apply to your organization

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Conquering Challenging Standards

Falguni Shah, M.Ed., LCPC

Associate Director, Standard Interpretation Group

Behavioral Health Accreditation

Scott Williams, Psy.D.

Director, Research Department

The Joint Commission

© Copyright, The Joint Commission

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2018 Top Compliance Issues

1. CTS.03.01.03 Treatment planning

62%

2. CTS.03.01.09 Outcomes measures

47%

3. NPSG.15.01.01 Suicide risk assessment

43%

4. CTS.02.01.11 Nutritional screening

43%

5. HRM.01.02.01 Verification of staff qualifications

41%

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2018 Top Compliance Issues

6. HRM.01.06.01 Staff competency

36%

7. CTS.02.02.05 Trauma Screening

28%

8. IC.02.04.01 Staff influenza vaccination

24%

9. CTS.02.01.09 Pain screening

22%

10. CTS.04.03.33 Food services

22%

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CTS.03.01.09 - Outcomes Measures(Effective January 1, 2018)

– Standard CTS.03.01.09 – The organization assesses the outcomes of care,

treatment, or services provided to the individual served

– EP 1 – The organization uses a standardized tool or instrument to monitors the

individual’s progress in achieving his or her care, treatment, or service goals

– EP 2 – The organization gathers and analyzes the data generated through

standardized monitoring, and the results are used to inform the goals and

objectives of the individual’s plan for care, treatment, or services as needed

– EP 3 – The organization evaluates the outcomes of care, treatment, or services

provided to the population(s) it serves by aggregating and analyzing the data

gathered through the standardized monitoring effort

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Selecting a Standardized Instrument

– In June 2017, The Joint Commission posted a list of instruments that could

be used to meet the new standard

– https://manual.jointcommission.org/BHCInstruments/WebHome

– We do NOT endorse any instrument, and the list is NOT intended to be

exclusive

– There are currently 66 instruments listed on the Joint Commission site

– Many are non-proprietary, cover a broad range of settings, and Include

individual instruments, as well as comprehensive systems

https://manual.jointcommission.org/BHCInstruments/WebHome

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What Kind of Instruments Meet the Requirement?

– The instrument should:

– Have well-established reliability and validity for use as a repeated

measure

– Be sensitive to change

– Be appropriate for use as a repeated measure

– Be capable of discriminating between populations that may or may not

benefit from services (if appropriate)

–e.g., clinical/non-clinical, healthy/non-healthy functioning, typical/non-

typical, etc.

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Measures NOT Complying with Standard CTS.03.01.09

– A measure that assesses the use of evidence-based care or clinical practice

guidelines

– A perception of care questionnaire or patient satisfaction survey

– A measure of medication/treatment compliance

– An assessment of outcome after the completion of service, even if it

compares a baseline score to a subsequent point of measurement (e.g.,

intake/termination, admission/discharge)

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Complying with Standard CTS.03.01.09− Select an instrument that is appropriate for measurement-based

care

− Administer it consistently throughout the care process

− Actually look at the data and do something in response to it

https://attendee.gotowebinar.com/register/7417914957620236547

Webinar Replay on this subject available at:

https://attendee.gotowebinar.com/register/7417914957620236547

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CTS.03.01.03 Treatment plans

⎻ EP 1 Assessed needs, goals of individual

⎻ EP 2 Goals expressed in a manner that captures the individual’s words or ideas

⎻ EP 3 Objectives included identified steps, sufficiently specific to assess progress, and provide indices of progress

⎻ EP 4 Re-evaluation and revision with changes, or at specified time intervals

⎻ EP 5 Treated, deferred, or referred

⎻ EP 6 Treatment plan followed

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NPSG.15.01.01 Suicide risk assessment

⎻ EP 1 Conduct environmental risk assessment

• Identify and mitigate

− EP 2 Screening for suicidal ideation

• Validated screening tool

− EP 3 Suicide risk assessment

• Evidence based process

− EP 4. Document

• Level of risk

• Plan to mitigate the risk

− EP 5 Policies and Procedures

− EP 6 Post discharge follow up care

− EP 7 Monitor and evaluate

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CTS.02.01.11 Nutritional screening

− EP 1 Everyone screened, triggers identified for assessment, e.g.

• Food allergies

• Weight loss or gain of ten pounds or more in the

last three months

• Decrease in food intake and/or appetite

• Dental problems

• Eating habits or behaviors that may be indicators

of an eating disorder, such as bingeing or inducing

vomiting,

⎻ EP 2 Assessments completed when indicated by qualified staff or referral to other resource

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HRM.01.02.01 Verification of staff

qualifications- EP 1 Primary source verification of staff licensure, certification,

registration

• At time of hire and renewal - Flagging for expiration date

• Date specific, no time gaps

• Criteria for external credential verification organization (CVO) are in glossary

⎻ EP 2 Verification of education and experience

− EP 3 Verification of identity

− EP 4 Criminal Background Check in accordance with law and regulation or organization policy

⎻ EP 5 Health screening in accordance with law and regulation or organization policy

⎻ EP 7 NPDB query at hire and at least once every two years

• Physicians and Dentists only

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HRM.01.06.01 Staff competency

⎻ EP 1 Program or service defined competencies

⎻ EP 2 Assessment conducted by staff with educational background, experience, or knowledge related to skills being reviewed

⎻ EP 3 Initial assessment during orientation

⎻ EP 5 Assessment at least once every 3 years, or more frequently as determined by organizational policy, or law and regulation

⎻ Documentation issues

⎻ Specific population competencies

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EP 1 Exploitation was a new elements added in Jan 2018

⎻ Initial and ongoing

⎻ Employee knowledge and training

⎻ Treatment or referral - Resources

CTS 02.02.05 - Screening for Trauma, Abuse, Neglect and Exploitation

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IC.02.04.01 Staff influenza Vaccination

⎻ EP 1 Must have annual influenza vaccination program

⎻ EP 2 Staff educated about influenza: vaccine; non-vaccine control and prevention measures; diagnosis, transmission, and

impact of influenza

⎻ EP 4 Goal of improving influenza vaccination rate in infection control plan

⎻ EP 5 Incremental goals consistent with achieving 90% influenza vaccination of staff by 2020

⎻ EP 7 Data collection of reasons for declining and analysis of data to better address following year

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CTS.02.01.09 Pain screening

⎻EP 1 Screening occurs for all individuals to provide for pain

assessment.

⎻EP 2 Organization treats identified individuals for pain or refers

individuals for pain treatment.

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CTS.04.03.33 Food services

⎻ EP 2 Food preparation under proper conditions of sanitation, temperature, light, moisture, ventilation, and security

⎻ EP 3 Food storage under proper conditions of sanitation, temperature, light, moisture, ventilation, and security

⎻ EP 6 Special diets and altered diet schedules accommodated

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Questions?

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Support throughout the process

The Behavioral Health Accreditation Team

― Available by phone or email, to walk organizations new to accreditation

through the entire process

― Complimentary webinars & workshops

― Access to online Behavioral Health Care accreditation manual (E-dition) trials

― Conference calls to help you address accreditation-related questions

― Presentations to Leadership/Governance Team

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Your Account Executive

― Ongoing support and assistance for accredited organizations

― Provides guidance on post-survey activities

― Contact info available on your Joint Commission Extranet site

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Assistance and Resources

Standards Interpretation Group (SIG)

̶ Experts on accreditation requirements

̶ Provide interpretation of standards

̶ Applicability of standards and elements of performance

̶ Engineer access for Life Safety Code questions

If you are already accredited, have submitted your application or are working on

your application and have a standards related question please submit your

question online:

http://web.jointcommission.org/sigsubmission/sigquestionform.aspx

(If your question concerns the Life Safety Chapter, please call 630/792-5900 and ask for a

Joint Commission engineer or email [email protected])

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http://web.jointcommission.org/sigsubmission/sigquestionform.aspx

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Online Resources

⎻ Behavioral Health Care web page

• Online tools to aid in the accreditation

process www.jointcommission.org/BHCS

⎻ Online resources for accreditation

• Secure extranet site (ICM tool, Survey

Activity Guide)

• Standards Portals

− New! Suicide Prevention Portal for revised standard effective 7/1

− Outcomes Measures page

• Standardized Tools page

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http://www.jointcommission.org/BHCShttps://www.jointcommission.org/topics/suicide_prevention_portal.aspxhttps://www.jointcommission.org/accreditation/bhc_new_outcome_measures_standard.aspxhttps://manual.jointcommission.org/BHCInstruments/WebHome?_ga=2.108616000.353132099.1565303742-1188625943.1563463391

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Joint Commission Free

Behavioral Health Webinars For information, replays or to register go to : Pages.JointCommission.org/BHC2019.html

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pages.jointcommission.org/BHC2019.html

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2019 Free Accreditation Workshop

Join us live!

⎻ Wednesday, August 21, 9 AM – 1:30 PM

⎻ Seacliff Country Club, Huntington Beach, CA

⎻ https://pages.jointcommission.org/BHC-2019-WorkshopCA.html

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Assistance and Resources

https://pages.jointcommission.org/BHC-2019-WorkshopCA.html

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Provides resources including software, consulting, publications and

educational opportunities: www.jcrinc.com

Joint Commission Resources (JCR)

http://www.jcrinc.com/

JCR Paid Webinar Series: 2019 Behavioral Health Care Breakfast Briefings

• Premier 11-part webinar series that will focus on Behavioral Health Care Standards, Challenging Standards, Survey Process, and Best Practices for Success

• Live 1 hour webinars on each standards chapter with opportunities for Q&A

• Available on-demand for one year after purchase, 24/7

For more information, visit:

https://www.jcrinc.com/2019-behavioral-health-care-breakfast-briefings/

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https://www.jcrinc.com/2019-behavioral-health-care-conference-october-23-24-2019/

https://www.jcrinc.com/2019-behavioral-health-care-conference-october-23-24-2019/https://www.jcrinc.com/2019-behavioral-health-care-conference-october-23-24-2019/

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Joint Commission

Behavioral Health Care Accreditation

The Joint Commission’s Gold Seal of ApprovalTM means your organization has reached for and achieved the highest level of performance recognition available in the behavioral health field.

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Behavioral Health Care Accreditation

Business Development Team

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Julia Finken, RN, BSN, MBA, CPHQ

Executive Director

[email protected]

630-792-5790

Peggy Lavin, LCSW

Associate Director –BHC

[email protected]

630-792-5131

Darrell Anderson

Manager- BHC

[email protected]

630-792-5866

Yvonne Rockwood, MBA,MHA,CPHQ

Associate Director – BHC

[email protected]

630-792-5792

Eastern Region Western Region

Tiffany Holloway

Manager - BHC

[email protected]

630-792-5810

Conquering Challenging Standards · 2019. 9. 16. · Behavioral Health Care Program ⎻Accrediting...

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Transcript of Conquering Challenging Standards · 2019. 9. 16. · Behavioral Health Care Program ⎻Accrediting...