Joint Commission Behavioral Health Care Accreditation Alaska Behavioral
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
The Joint Commission Behavioral Health Care Accreditation z Accrediting Behavioral Health Organizations since 1969 z Over 1, 800 Accredited Behavioral Health Care Organizations z Accredited Organizations range from small single service to complex multiple service providers 2
Behavioral Health Accreditation Program Comprehensive Accreditation Manual for Behavioral Health z Psychosocial Model – Community-based Mental Health & Psychosocial Services – Services for Children and Youth – Substance Abuse Treatment Services – Opioid Treatment Programs 3
“The Balancing Act” Evaluator and Educator Coach Mentor 4
The Surveyors z Experienced behavioral health care professionals z Trained, mentored and monitored z Helping organizations in their commitment to providing high quality safe services z Working with organizations to achieve and maintain compliance with highest standards of care 5
The Joint Commission Survey Process 6
Individual Tracer z Follow course of care, treatment or services provided z Assess relationships among staff and functions and person served z Evaluate performance of processes relevant to the person served 7
Individual Tracers continued z Usually at least 60% of survey z Assess relationships among staff and functions z Directly involves staff who provide services z Follows care, treatment or services throughout the organization z Person served is involved 8
Individual Tracer Visits May Include z z z 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 z Review of policies and procedures as needed z Review of staff HR files 9
System Tracer z Interactive session that explores important organization-wide process/functions related to safety and quality of care, treatment or services z Addresses: • Process flow, risk points, integration, communication, coordination • Strengths and areas needing improvement • Assesses standards compliance 10
System Tracer Activities z Provide a forum for discussion of important topics related to the safety and quality of care, treatment or services at the systems level z Relate to organization findings and structure z Allow exchange of educational information on key topics: • Medication management • Use of data • Suicide Prevention • Continuity of Foster Care • Violence Prevention 11
Scheduled When Applicable z Medication Management – Reviews the medication processes from ordering to administration – Only aspects relevant to organization 12
Building Tour z 24 -hour residences z Life Safety Code – Locked – Lodging or Rooming Houses – 4 to 16 occupants – Hotel and Dormitories – 17 + occupants z Environment preserves dignity z Day programs/out patient business occupancy z Food Storage and Dining z Medication Storage 13
Competence Assessment Session z 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 14
Data Session z Discussion of how the organization uses data z Identification of data to be collected z Aggregation and analysis z Use of the data for change z Performance Improvement Teams z Annual review of data plan 15
Leadership Session z z 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 16
Daily Briefing z Start of each day after the first z Review of the previous days activities z Identification of any areas of potential noncompliance with standards z Opportunity for organization to clarify misunderstandings 17
Closing Session and Report z Meeting with CEO, if desired, to review report z Meeting with staff chosen by organization z 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 18
Standards Requirements: z General performance expectations z General structure or process z Goal 19
Elements of Performance Requirements: z Specific performance expectation z Specific structure/process z Objectives z Scored 20
Standard Level Scoring z Elements of Performance are scored z Elements of Performance are aggregated to determine standards compliance z Standard is either in compliance or not in compliance 21
Accreditation Based on Impact on Care Treatment and Services Immediacy of risk to patient care and the organization’s accreditation status Higher “Sharp End” Timeline for resolution of non-compliant findings Immediate Threat To Life (PDA until resolved) Shorter Situational Decision Rules (Conditional Accreditation and Preliminary Denial of Accreditation ) Direct Impact Requirements “Implementation” Based Requirements (Short Resolution Timeframe) Lower Indirect Impact Requirements “Planning” and “Evaluation” Based Requirements (Longer Resolution Timeframe) Longer “Blunt End” 22
BHC Distribution by Impact 1% 13% Situational Decision Rules Direct Impact Requirements Indirect Impact Requirements 86% 23
Standards Applicability Process z Common Standards z Specific Program/Setting Standards z Specific Population/Service Standards z Relevant Steps in a Process such as Medication Management or Foster Care 28
Specific Programs and Settings z. Addictions z. Case management z. Corrections z. Crisis stabilization z. Family pres/wraparound z. Forensics z. Foster care z. Therapeutic foster care z. Alternative community programs/Alternative family living z. Residential/Group homes z. Out-patient z. Day programs z. Transitional/supervised living z. Vocational rehab. z. Outdoor z. On-line z. Opioid treatment z. Adult day care z. Therapeutic schools 29
Additional Behavioral Standards for Specific Populations z Children and Youth z Persons with Developmental Disabilities z Persons receiving Addiction Treatment or Services z Opioid Treatment Programs 30
Support for Accredited Organizations and Organizations Working Toward Accreditation z. Standards Interpretation Group (630) 792 -5900 z. Introduction to mentor organizations z. Complementary conference calls z. Educational programs z. Publications z. Designated Account Representative 32
Join us for the next free Behavioral Health Care teleconference: Standards Applicability -- Know What Applies to You November 11, 2009 12 noon CST 33
Joint Commission Behavioral Health Accreditation What will it do for your organization? z Demonstrates to the community the organization’s commitment to quality and safety. z Provides an outline for leadership to set goals, plan services, determine staffing, distribute resources, and manage risk. z Supports a culture of excellence. z Integrates data use into daily operations. z Supports board members in meeting their fiduciary responsibilities. 34
Joint Commission Behavioral Health Accreditation z Mary Cesare-Murphy, Ph. D. Executive Director, Behavioral Health Accreditation 630/792 -5790 mcesaremurphy@jointcommission. org z Peggy Lavin, LCSW Senior Associate Director, Behavioral Health Accreditation 630/792 -5411 plavin@jointcommission. org z Evelyn Choi, MS, MT(ASCP) Specialist, Behavioral Health Accreditation 630/792 -5866 echoi@jointcommission. org z Merlin Wessels Standards Interpretation 630/792 -5788 mwessels@jointcommission. org 35
The Gold Seal of Approval 36
- Slides: 31