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Joint CommissionBehavioral Health Care

Accreditation

Alaska Behavioral Health AssociationSubstance Abuse Director’s Association

Alaska Association of Homes for Children

September 15, 2009

Mary Cesare-Murphy, Ph.D. .Executive DirectorBehavioral Health AccreditationThe Joint Commission

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The Joint CommissionBehavioral 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

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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

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“The Balancing Act”

Evaluator EducatorCoachMentor

and

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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

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The Joint Commission Survey Process

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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

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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

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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

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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

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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

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Scheduled When Applicable

Medication Management– Reviews the medication processes from

ordering to administration– Only aspects relevant to organization

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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

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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

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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

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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

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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

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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

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Standards

Requirements:General performance expectationsGeneral structure or processGoal

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Elements of Performance

Requirements:Specific performance expectationSpecific structure/processObjectivesScored

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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

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Accreditation Based on Impact on Care Treatment and Services

ImmediateThreat To Life

(PDA until resolved)

Situational Decision Rules

(Conditional Accreditation and Preliminary Denial of Accreditation )

Direct Impact Requirements “Implementation” Based Requirements

(Short Resolution Timeframe)

Indirect Impact Requirements “Planning” and “Evaluation” Based Requirements

(Longer Resolution Timeframe)

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”

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BHC Distribution by Impact

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Standards Applicability Process

Common StandardsSpecific Program/Setting StandardsSpecific Population/Service StandardsRelevant Steps in a Process such as

Medication Management or Foster Care

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Specific Programs and Settings

AddictionsCase managementCorrectionsCrisis stabilizationFamily pres/wraparoundForensicsFoster careTherapeutic foster careAlternative community programs/Alternative family living

Residential/Group homesOut-patientDay programsTransitional/supervised livingVocational rehab.OutdoorOn-lineOpioid treatmentAdult day careTherapeutic schools

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Additional Behavioral Standards for Specific Populations

Children and Youth

Persons with Developmental Disabilities

Persons receiving Addiction Treatment or Services

Opioid Treatment Programs

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Support for Accredited Organizations and Organizations Working Toward Accreditation

Standards Interpretation Group(630) 792-5900

Introduction to mentor organizationsComplementary conference callsEducational programsPublicationsDesignated Account Representative

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Join us for the next freeBehavioral Health Care teleconference:

Standards Applicability -- Know What Applies to You

November 11, 200912 noon CST

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Joint Commission Behavioral Health AccreditationWhat 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.

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Joint Commission Behavioral Health Accreditation

Mary Cesare-Murphy, Ph.D.

Executive Director, Behavioral Health Accreditation

630/792-5790

mcesaremurphy@jointcommission.org

Peggy Lavin, LCSW

Senior Associate Director, Behavioral Health Accreditation

630/792-5411

plavin@jointcommission.org

Evelyn Choi, MS, MT(ASCP)

Specialist, Behavioral Health Accreditation

630/792-5866

echoi@jointcommission.org

Merlin Wessels

Standards Interpretation

630/792-5788

mwessels@jointcommission.org

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The Gold Seal of Approval