© Copyright, The Joint Commission Joint Commission Behavioral Health Care Accreditation Alaska Behavioral Health Association Substance Abuse Director’s Association Alaska Association of Homes for Children September 15, 2009 Mary Cesare-Murphy, Ph.D.. Executive Director Behavioral Health Accreditation The Joint Commission

© Copyright, The Joint Commission 2 The Joint Commission Behavioral Health Care Accreditation  Accrediting Behavioral Health Organizations since 1969  Over 1,800 Accredited Behavioral Health Care Organizations  Accredited Organizations range from small single service to complex multiple service providers

© Copyright, The Joint Commission 3 Behavioral Health Accreditation Program Comprehensive Accreditation Manual for Behavioral Health  Psychosocial Model –Community-based Mental Health & Psychosocial Services –Services for Children and Youth –Substance Abuse Treatment Services –Opioid Treatment Programs

© Copyright, The Joint Commission 4 “The Balancing Act” EvaluatorEducator Coach Mentor and

© Copyright, The Joint Commission 5 The Surveyors  Experienced behavioral health care professionals  Trained, mentored and monitored  Helping organizations in their commitment to providing high quality safe services  Working with organizations to achieve and maintain compliance with highest standards of care

© Copyright, The Joint Commission 6 The Joint Commission Survey Process

© Copyright, The Joint Commission 7 Individual Tracer  Follow course of care, treatment or services provided  Assess relationships among staff and functions and person served  Evaluate performance of processes relevant to the person served

© Copyright, The Joint Commission 8 Individual Tracers continued  Usually at least 60% of survey  Assess relationships among staff and functions  Directly involves staff who provide services  Follows care, treatment or services throughout the organization  Person served is involved

© Copyright, The Joint Commission 9 Individual Tracer Visits May Include  Observation of services  Observation of service planning process  Consumer, client, family interviews  Review of additional records as needed  Staff interaction Performance measurement Daily roles and responsibilities Training and orientation  Review of policies and procedures as needed  Review of staff HR files

© Copyright, The Joint Commission 10 System Tracer  Interactive session that explores important organization-wide process/functions related to safety and quality of care, treatment or services  Addresses: Process flow, risk points, integration, communication, coordination Strengths and areas needing improvement Assesses standards compliance

© Copyright, The Joint Commission 11 System Tracer Activities  Provide a forum for discussion of important topics related to the safety and quality of care, treatment or services at the systems level  Relate to organization findings and structure  Allow exchange of educational information on key topics: Medication management Use of data Suicide Prevention Continuity of Foster Care Violence Prevention

© Copyright, The Joint Commission 12 Scheduled When Applicable  Medication Management –Reviews the medication processes from ordering to administration –Only aspects relevant to organization

© Copyright, The Joint Commission 13 Building Tour  24-hour residences  Life Safety Code –Locked –Lodging or Rooming Houses – 4 to 16 occupants –Hotel and Dormitories – 17 + occupants  Environment preserves dignity  Day programs/out patient business occupancy  Food Storage and Dining  Medication Storage

© Copyright, The Joint Commission 14 Competence Assessment Session  Reviews processes the organization follows to ensure that they have sufficient, competent staff –Selection –Verification of education and licensure –Orientation and training –Competence assessment –Performance evaluation

© Copyright, The Joint Commission 15 Data Session  Discussion of how the organization uses data  Identification of data to be collected  Aggregation and analysis  Use of the data for change  Performance Improvement Teams  Annual review of data plan

© Copyright, The Joint Commission 16 Leadership Session  Discussion with leaders  Last day of survey  Based on observations during the survey  An opportunity for the leaders and surveyor to discuss how the leaders may be able to use the surveyors observations constructively

© Copyright, The Joint Commission 17 Daily Briefing  Start of each day after the first  Review of the previous days activities  Identification of any areas of potential non- compliance with standards  Opportunity for organization to clarify misunderstandings

© Copyright, The Joint Commission 18 Closing Session and Report  Meeting with CEO, if desired, to review report  Meeting with staff chosen by organization  Report –Provides clear explanation of any areas of noncompliance with standards –Written unofficial report of any findings –Official report is posted to your extranet site after central office review

© Copyright, The Joint Commission 19 Standards Requirements:  General performance expectations  General structure or process  Goal

© Copyright, The Joint Commission 20 Elements of Performance Requirements:  Specific performance expectation  Specific structure/process  Objectives  Scored

© Copyright, The Joint Commission 21 Standard Level Scoring  Elements of Performance are scored  Elements of Performance are aggregated to determine standards compliance  Standard is either in compliance or not in compliance

© Copyright, The Joint Commission 22 Accreditation Based on Impact on Care Treatment and Services Immediacy of risk to patient care and the organization’s accreditation status Lower Higher Timeline for resolution of non-compliant findings Shorter Longer “Sharp End” “Blunt End”

© Copyright, The Joint Commission 23 BHC Distribution by Impact

© Copyright, The Joint Commission 24 Accreditation Decision Process  Standards divided into –Direct Impact –Indirect Impact  Only Direct Impact count toward Central Office review  Central Office Review involves judgment  May result in Conditional Accreditation –Higher level of assurance that Requirements For Improvement (RFIs) are corrected

© Copyright, The Joint Commission Screening Points…  Program specific “screening points” developed based on the number of less than compliant direct impact standards or NPSGs  Screening points will trigger a review of findings by TJC Central Office Staff  Screening points are adjusted based on size and complexity (model uses surveyor days to differentiate)

© Copyright, The Joint Commission 26 Screening Points for Behavioral Health Organizations  Surveyor Days is 1-4:screening point is 5  Surveyor Days is =>5:screening point is 7

© Copyright, The Joint Commission 27 Internal review will result in…  Requirements for improvement to be addressed through evidence of standards compliance process  Recommendation for Conditional Accreditation –Includes a follow-up survey  Recommendation for Preliminary Denial of Accreditation –Immediate Threat to Life not identified at time of survey

© Copyright, The Joint Commission 28 Standards Applicability Process  Common Standards  Specific Program/Setting Standards  Specific Population/Service Standards  Relevant Steps in a Process such as Medication Management or Foster Care

© Copyright, The Joint Commission 29 Specific Programs and Settings  Addictions  Case management  Corrections  Crisis stabilization  Family pres/wraparound  Forensics  Foster care  Therapeutic foster care  Alternative community programs/Alternative family living  Residential/Group homes  Out-patient  Day programs  Transitional/supervised living  Vocational rehab.  Outdoor  On-line  Opioid treatment  Adult day care  Therapeutic schools

© Copyright, The Joint Commission 30 Additional Behavioral Standards for Specific Populations  Children and Youth  Persons with Developmental Disabilities  Persons receiving Addiction Treatment or Services  Opioid Treatment Programs

© Copyright, The Joint Commission 31 Examples of Applicability of Standards/Elements of Performance  Foster Care only: The agency defines and uses criteria to identify prospective foster care families  Opioid Treatment Program only: Concurrent abuse of other drugs is managed  Common: Leadership defines qualifications of staff and the number of staff needed to provide care, treatment or services

© Copyright, The Joint Commission 32 Support for Accredited Organizations and Organizations Working Toward Accreditation  Standards Interpretation Group (630)  Introduction to mentor organizations  Complementary conference calls  Educational programs  Publications  Designated Account Representative

© Copyright, The Joint Commission 33 Join us for the next free Behavioral Health Care teleconference: Standards Applicability -- Know What Applies to You November 11, noon CST

© Copyright, The Joint Commission 34 Joint Commission Behavioral Health Accreditation What will it do for your organization?  Demonstrates to the community the organization’s commitment to quality and safety.  Provides an outline for leadership to set goals, plan services, determine staffing, distribute resources, and manage risk.  Supports a culture of excellence.  Integrates data use into daily operations.  Supports board members in meeting their fiduciary responsibilities.

© Copyright, The Joint Commission 35 Joint Commission Behavioral Health Accreditation  Mary Cesare-Murphy, Ph.D. Executive Director, Behavioral Health Accreditation 630/  Peggy Lavin, LCSW Senior Associate Director, Behavioral Health Accreditation 630/  Evelyn Choi, MS, MT(ASCP) Specialist, Behavioral Health Accreditation 630/  Merlin Wessels Standards Interpretation 630/

© Copyright, The Joint Commission 36 The Gold Seal of Approval 