The instruction to follow is in the files. provide evidence from the scholarly articles and follow all the instructions in the browse file. 0 plagiarism. 300-400 words. I will like to work on
Privacy of Mental Health Records on my discussion. please read the instruction carefully.
Week 4 – Discussion
Behavioral Health Accreditation Standards
Prior to beginning work on this discussion, review the
2007 Guide to Joint Commission Behavioral Health Care Accreditation (Links to an external site.)
pdf. You will see that there are categories of areas that the organization looks at that are listed in this document. For example, in previous years, these categories have been: Quality Management and Improvement (QI), Coordination of Care (CC), Utilization Management (UM), Credentialing and Recredentialing (CR), and Members’ Rights and Responsibilities (RR). For your discussion, please pick one item from each of the updated standards listed in the linked document that you think is the most important item in that category, and briefly explain why you feel that it is so important. As you do this, consider what a consumer of your services might think about accreditation — does it make a difference to your consumers?
When you discuss the outcomes, refer to any specific standards that you may be currently using or considering. Feel free to add relevant examples, share relevant resources you have found (articles, videos, podcasts, infographics, quotes), share your relevant personal observations or experiences, and/or offer a short scenario as a realistic application of the concept.
Please provide an initial substantive answer between 300-400 words in length.
Introduction: Accreditation Bodies and Quality Management
Similar to the regulatory compliance landscape, private accreditation for behavioral health organizations is a complex and extensive process. There are three major private accreditation organizations in the United States that certify behavioral health organizations at different levels: The Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the National Committee for Quality Assurance (NCQA), and the Commission on Accreditation of Rehabilitation Facilities (CARF). Due to the complexity of this process, we will focus on the NCQA MBHO accreditation requirements here.
Resources
Required References
The Joint Commission. (2007). 2007 Guide to Joint Commission behavioral health care accreditation. Retrieved from
https://www.jointcommission.org/assets/1/18/BHC_Toolkit (Links to an external site.)
Willging, C., Sommerfeld, D., Aarons, G., & Waitzkin, H. (2014). The effects of behavioral health reform on safety-net institutions: A mixed-method assessment in a rural state. Administration & Policy in Mental Health & Mental Health Services Research, 41(2), 276-291. https://doi.org/10.1007/s10488-012-0465-1
World Health Organization. (2003). Quality improvement for mental health. Retrieved from
http://www.who.int/mental_health/resources/en/Quality (Links to an external site.)
Pgs. 32 – 53
Recommended References
Al-Sughayir, M. A. (2016). Effect of accreditation on length of stay in psychiatric inpatients: Pre-post accreditation medical record comparison. International Journal of Mental Health Systems, 10, 1-5. https://doi.org/10.1186/s13033-016-0090-6
American Psychological Association. (2010). Publication manual of the American Psychological Association (6th ed.). Washington, DC: Author.
APA Practice Organization. (n.d.) Legal issues. Retrieved from
http://www.apapracticecentral.org/legal/index.aspx (Links to an external site.)
CARF Behavioral Health. (2016). Providers. Retrieved from
http://www.carf.org/providers.aspx?Content=Content/Accreditation/Opportunities/BH/toc.htm (Links to an external site.)
The Joint Commission. (n.d.). Joint Commission FAQ page. Retrieved from
https://www.jointcommission.org/about/jointcommissionfaqs.aspx?CategoryId=14 (Links to an external site.)
The Joint Commission. (n.d.) Standards interpretation. Retrieved from
https://www.jointcommission.org/standards_information/jcfaq.aspx?ProgramId=4&ChapterId=0&IsFeatured=False&IsNew=False&Keyword= (Links to an external site.)
Lee, M. Y. (2014). Motivations to pursue accreditation in children’s mental health care: A Multiple case study. Nonprofit Management And Leadership, 24(3), 399-415.
Shallcross, L. (Ed.). (2012). What the future holds for the counseling profession. Retrieved from
http://ct.counseling.org/2012/03/what-the-future-holds-for-the-counseling-profession/ (Links to an external site.)
Smucker, B. (1999). The non-profit lobbying guide (2nd ed.). Independent Sector: Washington, DC. Retrieved from
https://conservationtools-production.s3.amazonaws.com/library_item_files/1102/1009/nonprofitlobbyingguide (Links to an external site.)
www.GoldSealofApproval.org
Behavioral
Health Care Accreditation:
Build a Framework to Support Quality in Everything You Do.
What do we hear from
our customers?
Provides a framework for organizational
structure and management
Strengthens community confidence in the
quality and safety of care, treatment and services
Provides ongoing resources and support
Is widely recognized by state authorities as
fulfilling regulatory requirements
Provides a risk management strategy
Provides a customized, intensive process of
review grounded in the unique mission and
values of the organization
“Our decision to be accredited is voluntary and
reflects our commitment to quality care. As a
publicly funded community behavioral health
center, we are under constant pressure from our
funders and payors to do more with less. Joint
Commission requirements are the standards we
use to assure we do not sacrifice quality or safety
as we change to meet new demands. They are
the stake pole around which we organize our
systems.”
Susan Rushing, PhD
Chief Executive Officer
Burke Center
Lufkin, TX
“The Astor Home for Children became one of
the first behavioral health care organizations to
achieve accreditation by the Joint Commission
in 1974. We believed then, as we do now, that
for Astor to be a world class organization, we
must set and meet the highest standards. Joint
Commission offers us the stringent standards
that insure our children and families receive the
care, treatment and educational services they
deserve.”
Jim McGuirk, PhD
Executive Director
The Astor Home for Children
Rhinebeck, NY
2007 Guide to
Joint Commission
Behavioral Health Care
Accreditation
Dear Reader,
It is my pleasure to extend a sincere thank you for your interest in Joint Commission accreditation
for behavioral health care organizations. At The Joint Commission, we understand that while the
accreditation process can be very rewarding, it can also be very challenging. That’s why we wrote
the Survey and Accreditation Process Guide. Our goal is to provide you with practical answers to
questions that are commonly asked by behavioral health care organizations. We hope you will find
the guide helpful whether you are considering accreditation for the first time, or you are currently
accredited and want to “brush up” on your knowledge of the accreditation process for behavioral
health care. I hope that this complimentary guide helps walk you through our policies and
procedures, standards, and survey process.
As a nationally recognized leader in accreditation, the Joint Commission is an independent,
objective evaluator of care quality. Accreditation from the Joint Commission is a “gold seal of
quality” and a mark of distinction for behavioral health care organizations. The Joint Commission is
the nation’s leading behavioral health accrediting body. Our customized standards and survey
process address a range of settings, services, and populations throughout the life span.
Feel free to call Behavioral Health Care Accreditation Services at (630) 792-5411 if you have
additional questions or need more information. In addition, we have provided a behavioral health
care accreditation staff directory within this booklet. We look forward to working with you!
Sincerely,
Mary Cesare-Murphy, PhD
Executive Director, Behavioral Health Accreditation Program
Behavioral Health Care Survey and Accreditation Process Guide
1
Table of Contents
Telephone Directory ………………………………………………………………………………………………………………………………. 2
The Joint Commission–Who Are We?……………………………………………………………………………………………………. 3
Joint Commission Behavioral Health Care Accreditation………………………………………………………………………… 3
Our Surveyors—Behavioral Health Care Professionals…………………………………………………………………………… 4
Our Standards Represent a National Consensus …………………………………………………………………………………….. 4
Eligibility for Survey ……………………………………………………………………………………………………………………………….. 6
Initial Surveys …………………………………………………………………………………………………………………………………………. 7
Early Survey Options ……………………………………………………………………………………………………………………………… 7
How to Apply ………………………………………………………………………………………………………………………………………… 10
The Standards Manual …………………………………………………………………………………………………………………………….. 11
National Patient Safety Goals………………………………………………………………………………………………………………….. 13
The On-Site Survey…………………………………………………………………………………………………………………………………. 13
Sample Survey Agenda ……………………………………………………………………………………………………………………………. 15
Scoring Guidelines and Decision Rules …………………………………………………………………………………………………..
18
Preparation Timeline……………………………………………………………………………………………………………………………….. 20
Notifying the Public About Accreditation……………………………………………………………………………………………….. 22
Survey Scheduling, Postponements and Delays ………………………………………………………………………………………. 22
Promoting Your Accreditation………………………………………………………………………………………………………………… 23
Appendix A: Joint Commission Behavioral Health Care Support Services and Resources………………………. 24
Appendix B: Survey Fees ………………………………………………………………………………………………………………………… 28
Appendix C: Foster Care…………………………………………………………………………………………………………………………. 29
Appendix D: Glossary …………………………………………………………………………………………………………………………….. 33
Behavioral Health Care Survey and Accreditation Process Guide
2
Telephone Directory
Staff Directory
Behavioral Health Care Accreditation Services
Mary Cesare-Murphy, PhD, Executive Director ……………………………………………………………. 630-792-5790
Peggy Lavin, LCSW, Associate Director ………………………………………………………………………… 630-792-5411
Jasmina Juric, Specialist ………………………………………………………………………………………………….. 630-792-5251
Susan Bullivant, Senior Secretary ……………………………………………………………………………………..630-792-5771
Standards Interpretation Group ………………………………………………………………………………………630-792-5900
To request a survey ………………………………………………………………………………………………………….630-792-5791
To inquire about survey fee information ………………………………………………………………………….630-792-5115
To contact your account representative……………………………………………………………………………630-792-3007
To request an Application for Accreditation ……………………………………………………………………630-792-5771
Customer Service Center ………………………………………………………………………………………………630-792-5800
To inquire about names of accredited organizations
Joint Commission Resources ……………………………………………………………………………………….877-223-6866
To inquire about field education, on-site education, video products, publications
information, or visit the JCR website at
www.jcrinc.com
Joint Commission Web Site: www.jointcommission.org
Current Joint Commission news
Quality CheckTM — information about accreditation status for specific organizations
Information about publicizing your accreditation
Frequently asked questions (FAQs)
BHC News (newsletter)
Revisions to standards
Speak Up information (look under “Top Spots” and then click on Speak Up)
“Helping You Choose” information for consumers (look under “General Public” then “Making
Better Health Care Choices”.) Click on the Behavioral Health Care information.
Joint Commission Resources Web Site: www.jcrinc.com
Upcoming education programs
Catalog of publications
Perspectives: The Official Joint Commission News Source
Behavioral Health Care Survey and Accreditation Process Guide
3
The Joint Commission–Who Are We?
The Joint Commission was founded in 1951 under the auspices of the American Hospital Association, the
American Medical Association, the American College of Physicians, and the American College of
Surgeons, with the later addition of the American Dental Association, to act as an independent accrediting
body for hospitals nationwide. Because of the changing nature of health care in America, the Joint
Commission has, over the years, broadened its scope to include accreditation of many non-hospital
settings including behavioral health care, beginning in 1969.
The Joint Commission established the Behavioral Health Care Accreditation Program to encourage quality
care in all types of freestanding behavioral health care facilities. Today’s behavioral health care
environment is changing rapidly, and providers are experiencing new quality and accountability pressures
in the behavioral health care marketplace. Providing safe, high quality care, treatment and services to
clients and continually improving performance are benchmarks of success. Joint Commission
accreditation of a behavioral health care organization is a widely recognized standard for high quality
services. Many payers, regulatory agencies, and managed care contractors require Joint Commission
accreditation for reimbursement, certification and licensure, and as a key element of participation
agreements.
Joint Commission Behavioral Health Care Accreditation
What accreditation means:
The Joint Commission is the nation’s leading accreditor of health care and behavioral health care
organizations. The Joint Commission accredits 15,000 organizations and services in the United States,
including over 1,800 behavioral healthcare organizations providing mental health care, addictions
treatment services, child welfare services, foster care, and services to persons with intellectual and
developmental disabilities. The Joint Commission’s role in the behavioral health care environment and
human services is well established and nationally renowned.
Organizations accredited by the Joint Commission benefit from the educational approach of the survey
process – the objective is to provide the organization with the information needed to improve its performance.
What accreditation means to the clients:
Joint Commission accreditation demonstrates to clients and their families that the organization has a
commitment to providing quality care, treatment and services. As the demand for greater accountability
for quality and cost grows, it is more important than ever to have the quality distinction – Joint
Commission accreditation. Achieving accreditation makes a strong statement to the community about an
organization’s efforts to provide care, treatment, and services of the highest quality.
What accreditation means to payers:
Joint Commission accreditation demonstrates quality in response to demands by payers, behavioral health
care policy makers and state authorities. Joint Commission accreditation can influence the decisions of
purchasers, expedite third party payment, reduce liability exposure, enhance community confidence, and
provide an organization with a higher level of recognition and acknowledgment.
Behavioral Health Care Survey and Accreditation Process Guide
4
In addition:
Since January 1, 2001, Joint Commission Foster Care standards have been available for organizations
that provide foster care. The standards address the continuum of care in the foster care process
from the child’s entrance into the foster care system; to whether the child returns to the family of
origin, is adopted, receives long term foster care, or becomes independent. See Appendix C for
further details.
Since January 1, 2001, Joint Commission standards for addictions treatment have been expanded to be
inclusive of chemical dependency, substance abuse, and other addictive behaviors, such as
gambling.
Joint Commission accreditation of Opioid Treatment Programs has had deemed status with the
Substance Abuse/Mental Health Services Administration (SAMHSA) since November, 2001. The
standards in the Comprehensive Accreditation Manual for Behavioral Health Care (CAMBHC) address the
full continuum of care for patients in both maintenance and detoxification modalities, including
mandatory requirements listed in federal regulation 42CFR Part 8. Opioid Treatment Programs
(OTPs) are also able to attend select customized training programs, supported by a grant from
SAMHSA.
State Recognition of Joint Commission accreditation
Many state authorities responsible for mental health/substance abuse/vocational
rehabilitation/intellectual and developmental disabilities organizations recognize Joint
Commission accreditation for purposes of licensure oversight or as a condition of funding. Please
check with the relevant state authority.
Our Surveyors — Behavioral Health Care Professionals
Joint Commission Behavioral Health Care staff and field surveyors are experienced Behavioral Health Care
(BHC) professionals who understand the day-to-day issues that confront you, and have the hands-on
expertise to help you resolve them. The Behavioral Health Care surveyor cadre is composed of clinical
psychologists, social workers, behavioral health care nurses, and administrators.
The Joint Commission ensures surveyor consistency by providing several weeks of initial training and
continuing education annually to keep surveyors up-to-date on advances in quality-related performance
evaluation. All surveyors have passed a Surveyor Certification Exam. Part of the training is ensuring that
your on-site survey is an educational process, not just a compliance experience.
The majority of the surveyors are also currently practicing in the behavioral health care field. The Joint
Commission evaluates its surveyors’ performance continually throughout the year.
Our Standards Represent a National Consensus
The Joint Commission’s behavioral health care standards and accreditation processes are the result of
careful analysis of this rapidly changing behavioral health care field. Every effort is made to reflect state-
Behavioral Health Care Survey and Accreditation Process Guide
5
of-the-art technology in behavioral health care and to provide reasonable guidelines that every behavioral
health care organization should strive to meet.
Professional and Technical Advisory Committee
Our standards undergo extensive field review prior to their publication. We have established a Professional
and Technical Advisory Committee (PTAC) to the Behavioral Health Care Accreditation Program, composed
of experts in the field. Our PTAC provides advice and assistance in the development of new and revised
standards, and recommends improvements to the accreditation process. Members of the Behavioral PTAC
are drawn from representatives of national bodies such as:
Alliance for Children and Families
American Academy of Child and Adolescent Psychiatry
American Association for Treatment of Opioid Dependence
American Association of Children’s Residential Treatment Centers
American College of Mental Health Administration
American Dental Association
American Hospital Association
American Medical Association
American Nurses’ Association
American Psychiatric Association
American Psychological Association
American Society of Addiction Medicine
Association for Ambulatory Behavioral Healthcare
Bazelon Center for Mental Health
Child Welfare League of America, Inc.
Coalition of Rehabilitation Therapy Organizations
Mental Health Corporation of America
National Association for Children’s Behavioral Health
National Association for the Mentally Ill
National Association of Addiction Treatment Providers
National Association of Alcoholism and Drug Abuse Counselors
National Association of Psychiatric Health Systems
National Association of Social Workers, Inc.
National Association of State Alcohol and Drug Abuse Directors
National Association of State Mental Health Program Directors
National Association of Therapeutic Schools and Programs
National Council for Community Behavioral Healthcare
Public Members
Substance Abuse and Mental Health Services Administration
Behavioral Health Advisory Council
On a regular basis, three groups of currently-accredited behavioral health care organizations, representing
community mental health centers, addiction treatment and behavioral health services for children and
youth, meet to discuss ongoing issues and potential future improvements to the accreditation process.
Behavioral Health Care Survey and Accreditation Process Guide
6
Eligibility for Survey
Any behavioral health care organization may apply for a Joint Commission accreditation survey under the
standards in the Comprehensive Accreditation Manual for Behavioral Healthcare (CAMBHC) if the following
requirements are met:
The behavioral health care organization is in the United States or its territories or, if outside the United
States, is operated by the United States government, under a charter of the United States Congress, or
for other behavioral health care organizations outside of the United States that meet the following
criteria:
The nature of the behavioral health care practices in the applicant organization is compatible with the
intents of Joint Commission standards;
With the use of available translators, as necessary, the surveyor(s) can effectively communicate with
substantially all of the organization management and clinical personnel and at least half of the
organization’s clients, and can understand clinical/case records and documents that relate to the
organization’s performance; or
United States citizens make up at least 10% of the organization’s client population
OR
A United States government agency contracts with the organization to provide services to United
States citizens
OR
United States citizens preferentially use the organization in that country.
The organization assesses and improves the quality of its services. This process includes a review of
care by clinicians, when appropriate.
The organization identifies the services it provides, indicating which services it provides directly, under
contract, or through some other arrangement.
The organization provides services addressed by the Joint Commission’s standards.
The Joint Commission surveys many types of organizations under the behavioral health care standards.
Accredited organizations may serve people throughout the life span or specialize in an age or disability
group. A standards applicability table in the CAMBHC identifies which standards apply to the various
settings and populations and includes:
• Addictions services/programs
• Case management
• Community mental health centers
• Corrections services/programs
• Crisis stabilization (24-hour acute care)
• Day programs (intensive outpatient services, day treatment programs, adult day care, therapeutic day
schools, and partial hospitalization programs)
• Family preservation/wraparound services
• Forensic programs or services
• Foster care, traditional
• In-home services
Behavioral Health Care Survey and Accreditation Process Guide
7
• Mental Health Rehabilitation Services
• On-line behavioral health
• Opioid treatment programs
• Outdoor behavioral health
• Outpatient programs
• Residential group homes
• Services that support recovery and resilience
• Therapeutic foster care
• Therapeutic schools (24 hour)
• Transitional living/supervised care/supportive care
• Vocational rehabilitation
Initial Surveys
An organization that is seeking Joint Commission accreditation for the first time or that has not been
unaccredited by the Joint Commission during the previous 6 months is eligible for an initial survey. The
full scope of applicable standards is reviewed during the survey. The scoring of the standards is based on a
4-month track record of compliance (prior to survey) rather than the 12-month track record of compliance
required for resurveys. The accreditation effective date for an organization that undergoes an initial survey
is the date on which its Evidence of Standards Compliance was submitted, if the organizaton has a
requirement for improvement. If there are no requirements for improvement, the effective date is the date
after the last day of the survey.
Early Survey Options (for organizations seeking accreditation but not ready for full
evaluation)
Early Survey Policy
Many organizations requesting a survey may be interested in accreditation, but do not feel quite ready for
full evaluation. These organizations may prefer to be surveyed under one of the two Early Survey
Options. An organization electing an Early Survey Option must declare that election on the Application
for Accreditation.
The Early Survey Policy allows a behavioral health organization new to Joint Commission accreditation to
enter the accreditation process in two stages. For a new organization, this makes it possible to set up the
business operations on a foundation of compliance with administrative and organizational standards
before the first clients are served. The Early Survey Options are different than a normal, full survey in that
they consist of two on-site visits.
Behavioral Health Care Survey and Accreditation Process Guide
8
Early Survey Option 1
First Survey
The first survey can be conducted as early as two months before the organization begins operations,
provided the organization meets the following criteria:
• it is licensed or has a provisional license;
• the building in which client care services will be provided is identified, constructed, and equipped to
support such services;
• it has identified its chief executive officer or administrator, and its director of clinical affairs; and
• it has identified the date it will begin operations.
The Joint Commission requires written evidence of these criteria within 30 days before conducting the first
survey.
The first survey is a limited survey, addressing physical environment, if applicable, policies and procedures,
plans, and related structural considerations for client care. Following this initial survey, assuming that the
organization can demonstrate compliance with the abbreviated set of standards, the organization receives
Preliminary Accreditation.
Second Survey
The second survey is conducted approximately six months after the initial survey, and covers the full set of
behavioral health accreditation standards, with a four-month record of compliance required. After
completion of the second survey, the organization receives one of the following accreditation decisions:
Accreditation, Provisional Accreditation, Conditional Accreditation, Preliminary Denial of Accreditation,
or Denial of Accreditation. The organization’s three-year accreditation cycle begins upon completion of
the second survey.
Early Survey Option 2
First Survey
Under Early Survey Option 2, to be eligible an organization that has never been accredited by the Joint
Commission must be in operation for at least one month, must have provided care, treatment or services
to at least 10 clients since the organization commenced operations, and must have at least one client under
active care, treatment or services at the time of the survey. The first survey is a full survey, assessing all
standards, without regard to track record. The organization is evaluated only for whether it is performing the
requirement, not the length of time it has been meeting the requirement. As a result of the first survey, the
organization may receive the following accreditation decisions: Accreditation with Requirements for
Improvement (to address the track record issues), Conditional Accreditation, or Preliminary Denial of
Accreditation.
Behavioral Health Care Survey and Accreditation Process Guide
9
Second Survey
The second survey is conducted four to six months after the first survey. The scope of the second survey
will depend on requirements for improvement from the first survey which need to be addressed, but will
always address track record requirements (at a minimum to address the four-month minimum record of
compliance with standards) which were not evaluated during the first survey. Based on the findings from
the first survey, follow-up activities such as Evidence of Standards Compliance may be required. The
result of the second survey may be continued Accreditation, Provisional Accreditation, Conditional
Accreditation, Preliminary Denial of Accreditation, or Denial of Accreditation.
Early Survey Options
Early Survey Option 1
First survey
• Conducted up to two months before opening
Licensed
Building identified, constructed, and equipped
CEO or administrator, director of clinical or
medical services (medical director), nurse
executive identified, if applicable
Identified opening date
• Limited set of standards (physical plant, policies
and procedures)
• Outcome: Preliminary Accreditation
Early Survey Option 2
First survey
• Conducted when an organization
Has been in operation at least one month
Has seen at least ten clients
Has one client in active treatment at time of
survey
• Full survey; no track record
• Outcome: Accreditation with requirements for
improvement, to address insufficient track record
of compliance, and other possible issues raised
during the survey; conditional accreditation; or
preliminary denial of accreditation.
Second Survey
• Six months after first survey
• Full survey
• Outcome: Change in preliminary accreditation
status to accreditation; provisional accreditation;
conditional accreditation; or preliminary denial of
accreditation. The effective date of the
accreditation decision is the day after the second
survey if there are no requirements for
improvement.
Second survey
• A full, follow-up survey four-six months after the
first survey
• Addresses track record and standards compliance
issues
• Outcome: Accreditation; provisional accreditation;
conditional accreditation; or preliminary denial of
accreditation. The effective date of the
accreditation decision is the day after the first
survey if there are no requirements for
improvement.
Converting a Full Survey to Early Survey Option 1
There are occasions when an organization has requested a full survey, but once the surveyor begins the on-
site evaluation, it becomes clear that the organization is not ready for a comprehensive review, and faces
the possibility of being denied accreditation. In that instance, the organization may be offered the option
to convert its full survey to a first survey for Early Survey Option 1. If the organization accepts, a second
survey is scheduled approximately six months later to address the issues discovered during the first survey.
However, the first survey of an early survey option cannot be converted into a full survey at the time of
survey.
Behavioral Health Care Survey and Accreditation Process Guide
10
How to Apply
An organization begins the accreditation process by completing an Application for Accreditation. This
electronic document provides essential information about an organization, including ownership,
demographics, and types and volume of services provided. The Joint Commission Application for
Accreditation is available on a secured organization-specific extranet site.
The Application for Accreditation:
Describes the organization seeking accreditation;
Requires the organization to provide Joint Commission surveyor(s) with all official records and reports
of public or publicly-recognized licensing, examining, reviewing, or planning bodies;
Authorizes the Joint Commission to obtain any such records and reports not possessed by the
organization; and,
When accepted, establishes the terms of the relationship between the organization and the Joint
Commission.
When completing out the Application for Accreditation, the organization identifies all services provided
and the location of each one. It is important that all the services provided are listed so the Joint
Commission can determine which standards apply to the organization and assign appropriate surveyor(s).
The Joint Commission schedules surveys based on information provided in the organization’s Application
for Accreditation. With the information provided, the Joint Commission determines the number of days
required for a survey and the composition of the survey team (number and discipline of surveyors).
Once the Joint Commission provides written or verbal notice of the scheduled survey date, it may
postpone the survey, without financial penalty, only when one or more of the following events happen:
A natural disaster or another major unforeseen event occurs that totally or substantially disrupts
operations;
The organization is involved in a major strike, has ceased admitting clients and is transferring
individuals served to other facilities;
Clients, the organization, or both are being moved to another building during the scheduled survey; or
The Joint Commission has provided less than four weeks advanced notice to the organization (by
telephone or in writing) of the survey date.
If none of these criteria are met and the organization wishes to postpone its survey, at the discretion of the
Joint Commission, the survey may be postponed for a fee equivalent to the base fee of the survey.
Role of the Account Representative
The Joint Commission assigns an account representative to each behavioral health care organization. This
person serves as the primary contact between the organization and the Joint Commission. He or she
coordinates survey planning and covers policies, procedures, accreditation issues or services, and inquiries
throughout the accreditation cycle. The surveyor and/or account representative will work with the
organization to customize its survey agenda to reflect its unique structure and characteristics. The
surveyor and/or account representative makes the most efficient use of staff and surveyor time during the
Behavioral Health Care Survey and Accreditation Process Guide
11
survey.
The Standards Manual
The Joint Commission’s CAMBHC is the place to begin when preparing for accreditation. Even if you do
not pursue accreditation right away, this manual is an excellent tool to help your organization become
organized and established. The CAMBHC contains functional standards that are organized around the
way care is provided in an behavioral health setting. The CAMBHC contains standards applicability tables,
so you can easily determine which standards apply to your specific setting, programs, services, and
population. (If your organization provides services other than behavioral health care, the Joint
Commission will work with you to determine which standards from other accreditation manuals may be
applied. For example, if a behavioral health organization provides ambulatory physical health services, the
Joint Commission tailors the survey to include the appropriate standards from the Comprehensive
Accreditation Manual for Ambulatory Services.) The standards address client-focused performance and are
organized around functions and processes, both clinical and organizational, common to all behavioral
health care organizations.
The CAMBHC is designed for use in self-assessment activities and is the basis for an accreditation survey.
The standards manual is divided into two sections: client-focused functions and organization functions.
Client-Focused Functions
The client-focused section includes chapters on Client Rights, Provision of Care, Medication Management
and Infection Control.
Ethics, Rights, and Responsibilities
These standards address issues such as promoting consideration of the client’s values; informing clients of
their responsibilities in the care process; and managing business practices in an ethical manner. Standards
regarding client rights with respect to informed consent, resolution of complaints and confidentiality are
included.
Provision of Care, Treatment, and Services
This chapter addresses assessment of clients, education of client and family, direct client care, monitoring
and determining the outcomes of care, and coordination of follow-up care. These standards cover
assessment, care, treatment, and services, and follow-up.
Medication Management
These standards address medication use, including availability, prescribing or ordering, preparation and
dispensing, administration and monitoring of effect. An organization may provide all, some, or none of
these medication processes, based on its mission, scope of services, and population(s) served.
Surveillance, Prevention, and Control of Infection
These standards address how the behavioral health provider identifies and reduces the risk of acquiring
and transmitting infections. Areas covered include case findings and how infections are reported.
Behavioral Health Care Survey and Accreditation Process Guide
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Organization Functions
This section of the CAMBHC includes chapters on Performance Improvement; Leadership; Environment
of Care; Human Resources; Information Management.
Improving Organization Performance
These standards focus on how well a behavioral health provider designs processes; measures its
performance; assesses its performance; and, ultimately, improves its performance. Examples of
improvement efforts include designing a new service; flowcharting a clinical process; measuring outcomes;
comparing performance with other like organizations; and selecting areas for priority attention.
Leadership
Effective leadership depends on the performance of the following processes:
Governance: The framework for supporting quality client care, treatment and services;
Management: Creating an environment that enables an organization to fulfull its mission and meet
or exceed its goals; providing a well-managed organization with clear lines of responsibility and
accountability;
Planning, designing, and providing services: A mission that provides organization, direction,
and appropriate staffing; communicating objectives and coordinating efforts;
Improving safety and quality of care: Leadership that is ultimately responsible for the safety of
all clients and staff; ensuring a process is in place to measure, assess, and improve the organization’s
governance, management, clinical, and support.
Management of the Environment of Care
These standards measure how well a safe, functional and effective environment for clients, staff, and other
individuals in the organization is being maintained. The following areas are addressed: emergency
preparedness, security, safety, life safety, equipment, utility systems, hazardous materials and waste
management.
Management of Human Resources
This chapter includes sections on human resources planning; orientation, training and education of staff;
competence assessment; credentialing practitioners; and assigning clinical responsibilities.
Management of Information
These standards address how well the behavioral health provider obtains, manages and uses information to
provide, coordinate and integrate services. The principles of good information management apply to all
methods, whether paper-based or electronic and Joint Commission standards are equally compatible with
either method. The chapter is divided into six sections:
Information Management Planning,
Confidentiality and Security,
Information Management Processes,
Information-Based Decision Making,
Knowledge-Based Information,
Clinical Data and Information.
Behavioral Health Care Survey and Accreditation Process Guide
13
National Patient Safety Goals
The Joint Commission issues a set of National Patient Safety Goals and Recommendations each year.
Aggregate data on achievement of the goals are made public each year.
For each of the National Patient Safety Goals, the Joint Commission has released evidence-based
recommendations to help behavioral health organizations reduce specific types of errors. Accredited
organizations that provide care relevant to the goals will be evaluated for compliance with the
recommendations or implementation of acceptable alternatives. The current goals and frequently asked
questions about the National Patient Safety Goals can be found on the Joint Commission web site,
www.jointcommission.org.
The On-Site Survey
The purpose of a Joint Commission accreditation survey is to assess the extent of an organization’s
compliance with applicable Joint Commission standards. Organizations undergoing their first survey need
to demonstrate a track record of four months of compliance with the standards. Organizations being
resurveyed need to demonstrate twelve months of compliance with the standards. Understanding the
organization and assessing compliance is accomplished through a number of methods including the
following:
receipt of verbal information concerning implementation of standards, or examples of their
implementation, enabling analysis of compliance;
observation of services;
observation of service planning process;
consumer, client and family interviews;
review of additional records, as needed;
staff-level interaction;
• performance measurement;
• daily roles and responsibilities
• training and orientation;
review of policies and procedures as needed.
Priority Focus Process
Priority Focus is a component of the on-site survey process that will allow surveyors to customize the
survey process to each organization. Organizations will find the Priority Focus Process to be information
driven, and to be focused on their specific performance.
Data sources that will contribute to the Priority Focus Process include:
Previous requirements for improvement from past surveys
Plan of Action from the Periodic Performance Review (see below)
Data from the completed Application for Accreditation
Complaints about the organization (if any) received by Joint Commission’s Office of Quality
Monitoring
Behavioral Health Care Survey and Accreditation Process Guide
14
(Priority focus for initial organizations is done, although the data set from which to pull information is
limited, basically to data from the application for accreditation completed by the organization.)
Tracer Methodology
Tracer Methodology is another component of the on-site survey that makes the client care experience the
‘table of contents’ to assess standards compliance. The surveyor(s) will select clients from an active client
list to ‘trace’ their experience throughout the organization.
The surveyor(s) will follow the client’s experience of care, treatment and services. This type of review is
designed to uncover systems issues, looking at both the individual components of an organization, and
how the components interact to provide safe and quality client care.
The number of clients followed under the Tracer Methodology will depend on the size and complexity of
the organization, and the length of the on-site survey. In addition to client tracers, when time permits,
surveyors also use the tracer methodology to assess key organizational activities appropriate to the setting
or services.
Periodic Performance Review
The Periodic Performance Review (PPR) is a key component in the more continuous accreditation
process. It is designed to help organizations incorporate Joint Commission standards as part of routine
operations and ongoing quality improvement efforts. An accredited organization has access to its PPR
tool on a continuous basis throughout its accreditation cycle. The PPR tool becomes available to
organizations seeking accreditation for the first time once they have submitted their application and
deposit (see page 28), but submission of the PPR to the Joint Commission is not required prior to an initial
accreditation.
The PPR tool permits the organization to self-assess compliance with all applicable standards and
Elements of Performance. For every noncompliant standard, the organization must identify a plan of
action at the Elements of Performance level which shows how it plans to come into compliance with the
requirement(s). This plan must include a Measure of Success, if applicable, for each Element of
Performance within a standard that is identified as not compliant and that requires a Measure of Succerss.
The Measure of Success is a numeric or other quantitative measure, usually related to an audit, that can
help determine whether a planned action was effective and sustained.
An organization is required to submit an annual update of its Periodic Performance Review to the Joint
Commission. The evaluation and plan of action must be completed electronically on the organization’s
secure extranet and transmitted to the Joint Commission by its annual due date. Following receipt of the
evaluation and plan of action (if it requested by the organization), staff from the Joint Commission’s
Standards Interpretation Group schedule a telephone call with the organization to discuss and agree upon
an acceptable plan of action. The time line for the Periodic Performance Review is such that the
organization should have sufficient time to implement the actions identified in the plan of action. The
track record will be based on the plan of action implementation date.
Behavioral Health Care Survey and Accreditation Process Guide
15
Sample Survey Agenda
DAY 1
Time Surveyor
8:00 – 9:00 a.m. Surveyor Arrival and Preliminary Planning Session
• Review the Priority Focus Process information
• Review the Periodic Performance Review and Plan(s) of Action (not applicable for
initial surveys)
• Quick overview of the Statement of Conditions (SOC) and Plans for Improvement
(PFI) if applicable (24-hour care settings, not including foster homes)
• Review list of eligible contracts*
• Review list of current clients
• Review of performance improvement and infection control data
• Select clients for individual tracer activities
Plan and confirm agenda activities
9:00 – 10:00 a.m. Opening Conference and Orientation to Organization
Introductions: Joint Commission surveyor(s) and key management staff.
Surveyor(s) will request the following materials for the Planning Meeting:
� List of active clients (by service/program) with name, address and diagnosis/condition
� High-level organization chart
� Identification of governance membership by background and consumer/non-
consumer status, if applicable
� Periodic Performance Review and Plan(s) of Action (not applicable for initial surveys)
� List of eligible contracts (direct services)*
� Environment of care management plans
� Policies/procedures for credentialing and assignment of clinical responsibilities
� Performance improvement data
� Infection control data
Orientation to behavioral health care organization
A high-level orientation to the organization (vision, mission, community, populations served,
etc.)
*Services or programs affected by your organization but a contracted service or program.
10:00 – 11:30 a.m. Continued Surveyor Planning Session
11:30 a.m. – 12:30 p.m. Life Safety Code® Building Assessment
Please Note: If the Life Safety Code® Building Assessment is not required, an additional
Individual Tracer Activity is substituted.
12:30 – 1:00 p.m. Surveyor Lunch
Behavioral Health Care Survey and Accreditation Process Guide
16
1:00 – 3:30 p.m. Individual Tracer Activity
Tracers will include:
� Observation of direct client care, treatment or services
� Observation of medication process (storage or administration), if applicable
� Observation of Environment of Care
� Performance improvement discussion at the staff level
� Review of open clinical/case records
� Staff discussion
� Review of policies, as needed
� Education, as applicable
Tracers may include:
� Client interview
� Review of closed clinical/case records
� Program/service visits
� Attend team meeting, if applicable
3:30 – 4:00 p.m. Special Issue Resolution
4:00 – 4:30 p.m. Surveyor Team Meeting / Planning Session
DAY 2
Time Surveyor
8:00 – 8:30 a.m. Daily Briefing
8:30 – 9:30 a.m. Individual Based System Tracer – Data Use
Discussion with staff regarding the use of data for improvement purposes
9:30 a.m. – 12:00 p.m. Individual Tracer Activity
12:00 – 12:30 p.m. Surveyor Lunch
12:30 – 1:00 p.m. Surveyor Team Meeting
1:00 – 3:30 p.m. Individual Tracer Activity
3:30 – 4:00 p.m. Special Issue Resolution
4:00 – 4:30 p.m. Surveyor Team Meeting / Planning Session
Behavioral Health Care Survey and Accreditation Process Guide
17
DAY 3
Time Surveyor
8:00 – 9:00 a.m. Leadership Session
• Discussion of critical systems analysis exploration – Leadership probes on some of
the critical processes
• Review of Periodic Performance Review Plans of Action (not applicable for initial
surveys)
• Discussion of organization-wide performance improvement activities as
appropriate to type and scope of services/programs
9:00 – 11:30 a.m. Individual Tracer Activity
11:30 a.m. – 12:30 p.m. Environment of Care Session
12:30 – 1:00 p.m. Surveyor Lunch
1:00 – 2:00 p.m. Competence Assessment Process
� Selected records will include behavioral health care professionals identified through
tracer activities
� Contract staff will be included in applicable
2:00 – 3:30 p.m. Surveyor Preparation of Findings
3:30 – 4:30 p.m. CEO Exit Briefing and Organization Exit Conference
Information Needed for the Preliminary Planning Session and Survey Planning Meeting
• Performance Improvement Data from the past 12 months
• Infection Control surveillance data from the past 12 months
• Environment of Care data as follows:
Statement of Conditions (SOC) and Plans for Improvement, (24-hour care setting, not including foster homes.)
Management Plans and annual evaluations, if applicable
Environment of Care multidisciplinary team meeting minutes for the 12 months prior to survey, if applicable
• An organization chart
• A map of the organization, if available
• List of areas/programs/services within the organization, if applicable
• Any reports or lists of clients (e.g., appointment schedule) that will help in identifying individuals to trace
• Name of key contact person who can assist surveyors in planning tracer selection
For further details on foster care accreditation, see appendix C.
Behavioral Health Care Survey and Accreditation Process Guide
18
Scoring Guidelines and Decision Rules
Background
Standards are formatted to include the following components:
Standard: A statement that defines the performance expectations and/or structures, or processes that
must be in place in order for an organization to provide safe, high quality care, treatment and services. An
organization is either “compliant” or “not compliant” with a standard.
Rationale: A statement that provides background, justification, or additional information about a
standard. A standard’s rationale is not scored. In some instances, the rationale for a standard is self-
evident. Therefore, not every standard has a written rationale.
Element of Performance (EP): The specific performance expectations and/or structures or processes
that must be in place in order for an organization to provide safe, high-quality care, treatment, and
services. The scoring of EP compliance determines an organization’s overall compliance with a standard.
Elements of Performance are evaluated on the following scale:
0=Insufficient compliance
1=Partial compliance
2=Satisfactory compliance
NA=Not applicable
Scoring Elements of Performance
Scoring guidelines have been developed to support Elements of Performance scoring decisions. Elements
of Performance have been grouped into three scoring criterion categories:
Category A. These Elements of Performance usually relate to structural requirements (for example,
policies, plans) that either exist or do not exist. They can be scored either 0 or 2, unless the track record
is deficient. (The track record is the amount of time that an organization has been in compliance with a
standard element of performance or other requirement). In this instance, to get a score 1, an
organization has a track record of 6 to 11 months (2 to 3 months for initial surveys). To get a score 2,
the organization needs a track record of 12 months or more (4 months or more for initial surveys).
Category B. These Elements of Performance may be structural or process requirements but also have
a qualitative component. They can be scored either 0 or 2, but score 1 (partial compliance) is also
possible. In some instances, the quality, adequacy, or comprehensiveness of the compliance may need
to be evaluated. In these instances, the organization must demonstrate that it has considered the
principles of good process design (as outlined in the standards).
Good process design
is consistent with the organization’s mission, values, and goals;
meets the needs of clients;
reflects the use of currently accepted practices (doing the right thing, using resources responsibly,
using practice guidelines);
incorporates current safety information and knowledge such as sentinel event data and National
Patient Safety Goals;
incorporates relevant performance improvement results; and
meets all components of the Elements of Performance.
Behavioral Health Care Survey and Accreditation Process Guide
The organization also needs to have the following track record:
Score Initial Survey Full Survey
2 4 months or more 12 months or more
1 2 to 3 months 6 to 11 months
0 <2 months <6 months
Use these rules to determine the Elements of Performance score:
The Elements of Performance score is 2 if the organization considered all applicable principles
above and meets the track record requirements above for score 2.
The Elements of Performance score is 1 if the organization considered only some of the
applicable principles above and/or meets the track record requirements above for score 1.
The Elements of Performance score is 0 if the organization did not consider any of the applicable
principles above and/or meets the track record requirements above for score 0.
Category C. These EPs are scored based on the number of times the organization does not meet the
particular EP (for example, something is only partially implemented, misses a frequency requirement,
or is not applied in all cases).
Standards Compliance
The following rules are used to determine compliance with the standard:
▪ The standard is not compliant if any Elements of Performance is scored 0.
The standard is compliant if 65% or more of the Elements of Performance are scored 2.
Accreditation Decision
An organization is accredited unless the number of non-complaint standards at the time of survey is three
standard deviations above the mean number of recommendations for all behavioral health care
organizations.
Post Survey Evidence of Standards Compliance
When requirements for improvement result from the on-site survey, an Evidence of Standards
Compliance (ESC) report is submitted by organizations within 45 days of the survey. This report
describes the actions the organization took (not planning to take) to bring itself into compliance with the
standard or clarifies why the organization believes it was in compliance with the standard at the time of
survey. An Evidence of Standards Compliance must address compliance at the Elements of Performance
level.
Some Elements of Performances will also require that organizations include a Measure of Success (MOS)
in the Evidence of Standards Compliance. A Measure of Success is a numerical or quantifiable measure,
usually related to an audit, that determines if an action was effective and is being sustained. In the initial
Evidence of Standards Compliance submission, an organization will identify its target Measure of Success.
19
Behavioral Health Care Survey and Accreditation Process Guide
20
Four months after the Evidence of Standards Compliance is approved, the organization submits aggregate
data demonstrating evidence of compliance.
Measures of Success are evaluated as follows: performance in the 90-100% range (score of 2); performance
in the 80-89% range (score of 1); performance at 79% or below (score of 0).
Preparation Timeline
Organizations Requesting a First Survey
Joint Commission Activity Your Activity
4-6 months before
preferred month of
survey
Call 630/792-5771 to obtain an Application for
Accreditation.
Upon receipt of
your call
Letter providing access to the Electronic
Application for Accreditation is mailed.
Staff member(s) with knowledge of your
organization’s services/programs, sites, and
client volume should complete and return the
Application for Accreditation with a $1,700
deposit for Initial survey/$1,000 for Opiod
Treatment Program Initial Survey that is applied
to your accreditation fees.
Upon receipt of
your Application
for Accreditation
and deposit
You are assigned an Account
Representative.
You will be mailed a complimentary
copy of the Comprehensive Accreditation
Manual for Behavioral Health Care
(CAMBHC).
You are given access to a
complimentary 6-month online
subscription to Perspectives: The Official
Newsletter of the Joint Commission.
You are given access to the Periodic
Performance Review tool.
Behavioral Health Care Survey and Accreditation Process Guide
21
All Organizations Requesting Accreditation
Joint Commission Activity Your Activity
Anually Invoice for annual fee is posted in
January.
Organization updates data contained in its
Application for Accreditation.
Survey Surveyor(s) arrives for on-site survey. At
the conclusion of the survey, you receive a
copy of the preliminary report, which
details partial or non-compliant areas that
need to be addressed.
During the survey, staff should be available as
outlined on the survey agenda.
2 days – 20 days
after survey
Final report is posted on your
organization’s extranet site. An email is
sent to alert your organization that the
final report has been posted. Invoice for
on-site fee is posted.
2 weeks after final
report is posted
Your organization’s description, contact
information, accreditation decision, and
status is updated for public viewing on the
Joint Commission Web site at
www.jointcommission.org via
QualityCheck®.
Within 45 days
after final report is
posted
Joint Commission reviews and approves
your Evidence of Standards Compliance.
For any standards scored as partial or non-
compliant, you submit your Evidence of
Standards Compliance to Joint Commission,
which identifies measures of success you will
track over the next four months to show
compliance.
6–8 weeks after the
final accreditation
decision
The Quality Report further expands on
the information already available on
QualityCheck®. It contains summary
information about an organization’s
performance relating specifically to Joint
Commission standards. Comparative
information from similar surveyed
organizations is also provided.
The Quality Report is not released until all
issues subject to review and/or revision have
been resolved. You will receive a copy of the
Quality Report for review, which includes an
opportunity to submit a commentary about the
Quality Report, prior to its being released to the
public.
For additional information about Quality
Reports, see the “Quality Report” chapter in the
CAMBHC.
Six months after
the accreditation
decision
You submit data to support measures of success
for partial or non-compliant standards from
your Evidence of Standards Compliance.
Monthly Each accredited organization is mailed
one copy of the Perspectives newsletter,
which is the official source for updates to
standards, policies, and procedures. (Also
available online)
Staff should review all changes featured in
Perspectives to keep abreast of changes and
developments in the standards and survey
process.
Annually The Periodic Performance Review (PPR) a self-
assessment form is completed by the
organization and submitted to the Joint
Commission. Complimentary consultation with
the Joint Commission’s Standards Interpretation
Group is available.
Behavioral Health Care Survey and Accreditation Process Guide
22
Twice annually Standards updates sent to each accredited
organization.
Staff should review the updates to act on new
and modified standards and elements of
performance, scoring guidelines, policies, and
procedures.
Within 30 days of
any significant
organizational
changes (as
defined in the
CAMBHC)
An organization update form for this
purpose can be found on the
organization’s extranet site. A decision
about appropriate follow-up will be made
based upon the type and extent of the
change.
The organization must notify Joint Commission
(via letter, fax, or e-mail) of any significant
change in the organization (as defined in the
“Official Accreditation Policies and Procedures”
chapter in the CAMBHC).
9–30 months
between triennial
surveys
Each year, a randomly selected 5% sample
of all accredited organizations will
undergo an unannounced survey based on
a select set of standards. The intent of
this unannounced survey process is to
ensure that organizations are compliant
with the standards throughout the entire
accreditation cycle.
Organizations that remain in compliance with
the standards throughout the accreditation cycle
will be prepared for a random unannounced
survey. There is no charge to organizations for
this type of survey.
Notifying the Public About Accreditation
An accredited organization is required to demonstrate how it notifies its public that quality and safety
concerns can be communicated to the Joint Commission. The organization may notify the public by
posting an accreditation certificate, posting information on its web site and/or in client admission
brochures, or by using any other effective means of its choice.
Survey Scheduling, Postponements and Delays
Schedule for Initial Surveys
The Joint Commission schedules surveys systematically and efficiently to keep accreditation fees to a
minimum. Therefore, organizations are encouraged to accept scheduled survey dates. Initial surveys, that
is, an organization’s first full accreditation survey, must be scheduled within six months from the time the
Joint Commission receives the organization’s Application for Accreditation. The organization indicates in
the application the month requested for the on-site survey.
The Joint Commission tries to honor specifically requested dates during which an organization prefers not
to be surveyed. The organization should include specific dates with the completed Application for
Accreditation, whenever possible. There may, however, be circumstances that prevent the Joint
Commission from accommodating these dates.
Behavioral Health Care Survey and Accreditation Process Guide
23
Definition of Postponements and Delays
The Joint Commission also provides for the postponement or delay of initial surveys. A postponement is an
organization’s request to alter an already-scheduled survey date. A delay is an organization’s request to push
back the survey date before it is actually scheduled. An organization should direct a request for a
postponement or delay to its Account Representative.
Length of Postponement or Delay
A survey ordinarily may be postponed or delayed for no more than six months. For an organization due
for resurvey, the Joint Commission will conduct an on-site extension survey if the original survey is
postponed or delayed for more than six months.
Timeliness of Application and Deposits
The Joint Commission requires an organization to submit a new Application for Accreditation if the
organization does not accept a scheduled survey within six months. This assures that the organization’s
information is current.
Promoting Your Accreditation
Once you have achieved accredited status, you should promote that status to the public, third-party payers,
and client referral sources. Every accredited organization has access to a publicity kit that contains
• suggestions for publicly celebrating your accreditation,
• sample news releases and other publicity guidelines,
• information on ready-made promotional materials you can purchase, and
• guidelines for use of the Joint Commission Gold Seal of ApprovalTM, and instructions for
downloading artwork.
It is highly recommended, as your printing budget allows, to include the Joint Commission’s Gold Seal of
Approval on any items seen by the public, or your payers, including:
• Business cards
• Web site
• Building signs
• Invoices
• Stationery
• Advertising
Information about your accreditation status will be posted in QualityCheckTM on the Joint Commission
web site. QualityCheck allows anyone to search for accredited organizations within a city or state, or by
type of setting.
Behavioral Health Care Survey and Accreditation Process Guide
24
Appendix A
THE JOINT COMMISSION – SUPPORT SERVICES AND RESOURCES CURRENTLY
AVAILABLE TO ACCREDITED BEHAVIORAL HEALTH CARE ORGANIZATIONS
The Joint Commission offers behavioral health care organizations a comprehensive body of standards to
guide them in providing quality behavioral health care services and in performance improvement.
Compliance with these standards is assessed during onsite survey visits generally occurring every three
years, and through annual Periodic Performance Reviews. Achieving accreditation validates the high
caliber of the services the organization provides and clearly indicates to customers that the organization is
quality-driven and has exceeded the “minimal standards” imposed by regulatory agencies.
In addition to the standards and the accreditation survey, the Joint Commission also offers accredited
organizations a variety of support services on a continual basis. A list of Joint Commission Behavioral
Health Care contacts is on page 2 because the expert knowledge of our dedicated staff is the greatest
resource the Joint Commission offers to customers.
A summary of some of Joint Commission’s Behavioral Health Care support services and resources
appears in the following matrix:
Service Description Cost Contact Comments
Standards
Interpretation
Group (SIG)
Expert behavioral health care
professionals available by
phone, mail or e-mail to
assist organizations in
interpreting the standards
and in offering advice about
successfully meeting the
intent of the standards.
No charge Call 630-792-5900 or
complete a standard form
on-line
SIG also includes
engineers who are experts
in risk management and
physical environment
safety and are available to
advise organizations
about compliance with
the Environment of Care
standards.
The Joint
Commission Web
Site
Available online via the
Internet, this site offers a
wealth of information for
behavioral healthcare
providers, consumers and
others. Offerings include:
quality updates, standards
clarifications, advice about
compliance with frequently
scored standards, and
information about “what’s
new” at the Joint
Commission.
No charge www.jointcommission.org The standards
interpretation form is
available on this site. The
site also offers valuable
links to other web sites.
Behavioral Health Care Survey and Accreditation Process Guide
25
“Quality Check” Available online and by
telephone, this service
allows individuals needing a
Behavioral Health Care
provider to search for Joint
Commission accredited
organizations by name
and/or geographic location.
No charge Online at
www.jointcommission.org
or call customer service at
630-792-5800
“Quality Check”
demonstrates to your
current and future
customers that you are a
quality-driven, accredited
Behavioral Health Care
provider.
Helping You
Choose..Quality
Behavioral Health
Members of the public
often contact Joint
Commission for advice
about selecting quality
behavioral health care
providers. “Helping You
Choose” brochures are sent
to these individuals to help
them assess and evaluate
quality providers.
No charge
Call customer service at
630-792-5800
Also request these
brochures online at
www.jointcommission.org
or by mail addressed to
The Joint Commission,
One Renaissance Blvd.,
Oakbrook Terrace, IL
60181.
Joint Commission
Perspectives
The Joint Commission’s
official newsletter. This
publication is published
monthly and mailed to all
accredited organizations to
advise them about the Joint
Commission initiatives,
policy changes, and news
updates.
No charge to
accredited
organizations
Automatically mailed
(electronically or print
version) to all accredited
organizations.
Additional copies of
Perspectives may be
purchased by calling 1-800-
346-0085 ext. 558 or online
at www.jcrinc.com. Each
year Perspectives publishes
information about the
standards that are most
frequently scored as “non-
compliant” for each
accreditation program.
The Inside
Perspective
Joint Commission’s monthly
news brief
No charge to
accredited
organizations
Automatically faxed to all
accredited organizations.
Also available online at
www.jointcommission.org
or call 630-792-5800.
BHC News Published four times/year
to address the unique
concerns of Behavioral
Health Care providers.
Articles may include
behavioral health care news
and quality updates,
compliance advice and
educational resource
information.
No charge to
accredited
organizations
Automatically emailed to
registered organizations.
To sign up to receive the
newsletter online, go to
www.jointcommission.org.
Call 630-792-5800 for
more information.
Behavioral Health
Care
Teleconferences
Complimentary
teleconferences providing
overviews of accreditation,
with time for questions.
No charge To register, call 630-792-
5825, or email
aquartz@jointcommission.
org
Gives multiple staff an
opportunity to ask
questions of the experts in
preparing for survey.
Behavioral Health Care Survey and Accreditation Process Guide
26
Comprehensive
Accreditation
Manual for
Behavioral Health
Care (CAMBHC)
The CAMBHC is the heart
of the Joint Commission’s
behavioral health care
accreditation program. It
includes information about
accreditation participation, all
of the Behavioral Health
Care Standards, a glossary,
Standards Applicability
Tables and more.
No charge,
included in the
request for
accreditation fee.
One copy of the
Manual is sent when
you first apply for
accreditation. Updates
are automatically
mailed to accredited
organizations at no
extra charge twice a
year.
Additional copies of the
Manual may be purchased
by calling 1-877-223-6866
or online at
www.jcrinc.com.
An automated version of
the manual is also available
for purchase. In addition,
a handy “abridged” version
(standards and elements of
performance only) is
available for a reduced fee.
Survey And
Accreditation
Process Guide
The Survey & Accreditation
Process Guide is a handy
reference designed to help
organizations apply for and
prepare for accreditation.
No charge,
included in the
Application for
Accreditation.
For initial surveys call
630-792-5411. For
resurveys call 630-792-
3007 or your Account
Representative.
This guide is automatically
sent to behavioral health
care organizations that ask
for an application for
accreditation.
Office of
Government
Relations
Joint Commission
representatives work closely
with federal and state
legislative representatives
regarding behavioral
healthcare regulation and
legislation to promote the
quality and safety of the
services the public receives.
No charge For federal legislation
call the Joint
Commission’s
Washington office at:
202-783-6655. For
state legislation call:
630-792-5260 or
630-792-5261.
For more information
about the Joint
Commission’s government
relations see the Joint
Commission’s web page at
www.jointcommission.org
Behavioral Health
Care Professional
And Technical
Advisory
Committee
The Committee advises the
Joint Commission on
standards development. It
includes representatives from
Behavioral Health Care
national trade and
professional associations and
customers. This advisory
committee two to three times
per year.
No charge.
The
composition of
the Committee
determined by
the Joint
Commission
Board of
Commissioners.
Call 630-792-5411 or
630-792-5771 for
information about
Committee members
or activities.
The Joint Commission
solicits input from its’
customers via the
committees. In addition,
every year a “Liaison
Network” is convened to
promote communication
and enhance the
accreditation process
The Ernest Amory
Codman Award
The Joint Commission
recognizes outstanding
achievements in quality and
performance improvement
by granting annual Codman
awards.
Application fee. Call customer service
at 630-792-5800. The
application deadline is
in February each year.
All organizations applying
for a Codman award
receive a peer-reviewed
evaluation of their
performance improvement
initiative.
Behavioral Health Care Survey and Accreditation Process Guide
27
Joint Commission
Resources
Educational
Programs
Joint Commission
Resources (JCR) offers a
variety of behavioral health
care educational programs
in various locations
throughout the year.
Varies per
program.
Call 1-877-223-6866 for
specific program
information or register
online at www.jcrinc.com.
Also, look for Joint
Commission participation
at various trade shows and
professional society
meetings throughout the
year.
Joint Commission
Resources
Multimedia
Publications and
Products
Joint Commission
Resources (JCR) sells a
variety of helpful and
authoritative publications
and multi-media products to
assist behavioral health care
organizations to: improve
processes, promote care,
enhance quality and
demonstrate standards
compliance.
Varies per
service
requested.
Visit JCR online at
www.jcrinc.com or call
630-268-7400.
JCR also offers
international accreditation
services.
Joint Commission
Satellite Network
(JCSN)
JCSN is a “distance
education” option that
allows participants to
interact with “live” satellite,
educational program
broadcasts. JCSN delivers
award-winning programs to
healthcare providers in
many fields.
Varies with
the services
selected.
Contact JCSN Territory
Manager or an Education
Consultant at
1-800-711-6549 for:
Sales
Renewals
Implementations
Service
Broadcast Schedule
Programs can be taped and
used for internal education
purposes.
Joint Commission
Speaker’s Bureau
Joint Commission Speakers
Bureau offer qualified
speakers on a variety of
topics related to Joint
Commission accreditation,
performance measurement,
quality improvement, etc.
Varies with
request,
generally the
standard fee
for a speaker
is $1000 plus
travel and
expenses.
Call 630-792-5633 for
more information. Also
see the Joint Commission’s
web page at
www.jointcommission.org.
To match the best speaker
with the program we
recommend the requester
contact the Joint
Commission as early as
possible—at least eight
weeks before the
scheduled event.
Speak Up!
Brochures
The content of this
brochure provides simple
advice on how you, as the
client, can make your care a
positive experience. It’s
available for a variety of
health care settings.
The Speak Up
brochure is
available by
accreditation
program, in
three formats:
Call customer service at
630-792-5800
Also request these
brochures online at
www.jointcommission.org
or by mail addressed to
The Joint Commission,
One Renaissance Blvd.,
Oakbrook Terrace, IL
60181.
Behavioral Health Care Survey and Accreditation Process Guide
28
Appendix B: Survey Fees
The Joint Commission utilizes subscription billing for all programs, except opioid treatment providers.
For all accredited programs, the subscription approach involves an annual billing at a base rate and the
assessment of an add-on fee to cover survey-related costs when an on-site survey is conducted. The use of
an annual fee subscription approach is more consistent with the continuous nature of the Joint
Commission’s current accreditation process.
The non-refundable annual fee is assessed on each accredited organization and is due each January. The
annual fee for an organization is determined based on the organization’s size and complexity. The annual
fee for an organization applying for accreditation for the first time will be prorated, based on the quarter in
which the application for accreditation and deposit is submitted.
In addition to annual fees, organization are billed an on-site survey fee after the survey has been
performed. The on-site survey fee, which is designed to cover the costs of performing a survey, is due
upon receipt. Other types of surveys, such as conditional follow-up surveys and PPR surveys, are charged
separately once the event has occurred.
A nonrefundable, non-transferable survey deposit of $1,700 ($1,000 for opioid treatment programs) is
required for initial surveys only. The Joint Commission applies the deposit to the organization’s
accreditation fee when the survey is conducted within six months of receipt.
To calculate an estimate of your accreditation fees, please request the Accreditation Fees for Behavioral Health Care sheet, or
call 630-792-5115.
Behavioral Health Care Survey and Accreditation Process Guide
Appendix C: Foster Care
It is necessary to visit families caring for children in foster care to assess the safety and the quality of the
care available to foster children. At a minimum, home visits include the following elements:
• Observation of care.
• Assessment of environmental safety issues in foster homes.
Selection of Foster Families for Home Visits:
Home visits to current foster children/youth will be conducted by a surveyor(s). Generally, each surveyor
will conduct two to three home visits on each day of the survey except for the last day of the survey1.
In preparation for the home visits, the organization needs to select 10% of their current foster
children/youth who live approximately 30 minutes or less travel time from each foster care office/site
(small foster care programs should select at least twelve homes total). The selected 10% will be informed
by the organization that Joint Commission surveyor(s) may be conducting a home visit in their residence
to observe care and service and to conduct interviews with the caregiver(s) and the children/youth
involved in the foster care program.
At the time of the survey, each surveyor will generally select one case manager per survey day responsible
for two to three foster homes in the identified selection group. The selected case manager(s) will be asked
to confirm appointments and to travel with the surveyor on the home visits.
In organizations whose primary mission is foster care, more visits will be appropriate.
The organization is asked to obtain verbal permission for the home visit from the foster parent in advance.
At the time of the actual visit the organization is asked to obtain written permission for surveyors to visit
the foster home. Please refer to page 33 for an example of a form that organizations may choose to use
for this purpose.
Joint Commission Visits to Foster Care Homes
Generally, a home visit lasts 20 to 30 minutes. The organization needs to confirm that the foster
child/youth will be at home with one or both caregivers at the time designated by the surveyor(s) and the
organization. The designated time is preferably after school or other day programs.
The organization explains in detail the Joint Commission survey process to the foster parents and foster
children, including an explanation of the interviews that will take place with the foster care parents and
children/youth.
1A group meeting of foster parents is substituted for one day of home visits.
The case manager for the foster child/youth should accompany the surveyor during the home visit, as well
as other representatives as determined by the organization. The surveyor will generally conduct the home
visit towards mid-afternoon or early evening and will not return to the organization until the next survey
day.
29
Behavioral Health Care Survey and Accreditation Process Guide
30
General Information about Foster Care Home Visits:
A staff member from the agency (preferably the designated case worker) accompanies the surveyor to the
home visit. In order to maximize productive survey time, the surveyor should ride with a staff
member/case worker to home visits.
Generally, the surveyor will review the child’s case file and the foster family’s file before the home visit.
During the home visit, the surveyor may ask to see the foster family’s license, medication logs (if
appropriate) and foster parent’s manual if available.
Meeting Between Foster Parents and Joint Commission Surveyors
The Joint Commission requires an organization with foster care services/programs to provide
opportunities during an initial or triennial survey for the presentation of information by foster parents.
This will be accomplished via visits to the foster homes to interview the foster parents and the foster
children/youth . The Joint Commission requires a meeting between the foster parents and the surveyor(s.)
The expectation is that the meeting will include foster parents who are representative of all the foster care
services the agency provides.
2
2The expectation is that the organization undergoing survey and the surveyor will make every effort to
arrange a meeting of foster parents and surveyors as described here. If it is impossible to convene a foster
parents meeting during survey, the surveyor will make arrangements with the organization to visit
additional foster homes.
The purpose of this meeting is to provide the surveyor with information about the foster parents’
experiences in providing quality foster care. This is an informal meeting in which the surveyor(s) will learn
about recruitment, licensing, and training processes; the preparation of the foster parents to meet the
needs of children, in general, and the specific needs of the children placed in their homes; how the
organization continues to support the foster parents and other issues related to foster care.
The foster parent/surveyor(s) meeting may be held any afternoon or evening of the survey (except for the
last day). The organization is responsible for making the meeting arrangements and notifying each (all)
foster parents of the exact date, time and place of the foster parents/surveyor(s) meeting. On pages 37 and
38 are examples of a notice of a meeting for foster parents permission for a foster home visit and the
selection process for foster homes to be visited by the surveyor(s) during the survey.
If the organization holds a regularly scheduled meeting with foster parents for training, education,
communication purposes, the surveyor will explore the possibility of using the regularly scheduled meeting
to meet with the foster parents.
Behavioral Health Care Survey and Accreditation Process Guide
31
The organization is expected to provide a reasonable, accessible meeting location. Surveyor(s) conduct the
meeting and receive the information. Representatives of the organization familiar with the organization’s
foster care services/programs and foster parents are expected to attend.
EXAMPLE
NOTICE:
MEETING FOR FOSTER PARENTS WITH JOINT COMMISSION SURVEYORS
The Joint Commission will conduct an accreditation survey of
___________________________________________________________(name of organization)
on __________________________________(survey dates.)
The purpose of this survey will be to evaluate the organization’s compliance with nationally established Joint
Commission standards that evaluate foster care quality and safety issues. In order to accomplish this goal, the
Joint Commission and your foster care organization invite you to attend a meeting of foster parents in order to
meet the Joint Commission surveyor(s).
This meeting will assist Joint Commission surveyor(s) in learning about your experiences as a foster parent.
This is an informal meeting in which the surveyor(s) will be interested in hearing from you about your
recruitment, licensing, training experiences, the preparation that you received to prepare you for children being
placed in your home, the quality of the support you receive and other issues related to foster care.
We hope that you will be able to attend this important meeting.
Date:____________________________
Time:____________________________
Location:_________________________________
Contact person:_____________________________ Phone number: _______________________
Please notify us is if you will be able to attend this meeting. Thank you.
Behavioral Health Care Survey and Accreditation Process Guide
32
EXAMPLE
PERMISSION FOR JOINT COMMISSION SURVEYOR(S) TO CONDUCT
A FOSTER HOME VISIT
The Joint Commission will conduct an accreditation
survey of ________________________________________________________ (name of organization)
on _________________________________________(survey dates.)
The purpose of this survey will be to evaluate the organization’s compliance with nationally established Joint
Commission standards that evaluate foster care quality and safety issues. In order to accomplish this goal, your
permission is requested to permit Joint Commission surveyor(s) to visit your home to learn about your
experiences as a foster family.
This is an informal visit in which the surveyor(s) will be interested in hearing from you about foster
parent/foster family recruitment, licensing, training experiences, the preparation that you received to prepare
you for children being placed in your home, the quality of the support you receive from the organization, and
other issues related to foster care. If appropriate, the surveyor will also speak to the foster child/youth in order
to learn about his/her experiences in foster care.
My signature below indicates that I have given permission for Joint Commission surveyor(s) to visit
my home for the purpose of surveying compliance with Joint Commission foster care standards.
Signed:____________________________________________________________ (foster parent)
Signed: ______________________________________, _____________________________(title)
of_______________________________________________________________(name of organization )
Date:____________________
Behavioral Health Care Survey and Accreditation Process Guide
33
Appendix D
GLOSSARY
Addictions services/programs – Behavioral health care services/programs for the assessment and/or
treatment/care of individuals with addictive behaviors, such as substance abuse, chemical dependency,
gambling, etc.
Behavioral health – A broad array of mental health, foster care, chemical dependency, forensic,
developmental disabilities, and cognitive rehabilitation services provided in settings such as acute, long
term, and outpatient.
Care coordination – Assistance provided to clients or their authorized representatives in planning and
organizing behavioral health and other relevant community resources. (Authorized means given legal
power.)
Case management services – The ongoing provision of service aimed at assessing needs, linking
community resources, and delivering flexible problem solving and crisis response (such as assertive
community treatment, wrap-around services, and family preservation).
Community integration – Assistance in maintaining or moving toward independent community living.
Corrections services – Behavioral health care services provided in a correctional setting.
Crisis stabilization – A highly structured environment for individuals who require 24-hour registered
nursing supervision and who may be incapable of self-preservation in case of an internal disaster. Crisis
stabilization is typically characterized by a short length of stay with discharge or transfer to a hospital or
community-based services.
Day treatment/intensive outpatient/partial hospitalization/adult day care services – An
environment offering an organized day or night program of assessment, treatment, care, services,
habilitation, or rehabilitation for individuals not requiring 24-hour care. For behavioral health, this may be
a structured, ongoing program that typically meets 2 to 5 times a week for 2 to 5 hours per day.
Employment services – A formal or informal process of assisting the client in finding and/or
maintaining employment as part of general care treatment or services being provided. This term is not
synonymous with vocational rehabilitation.
Family preservation – Organizations providing and/or coordinating services for a child, youth, and the
child or youth’s family with the goal of maintaining the child or youth in her or his family and/or
community.
Family support – A family member assuming the role and responsibilities of a member of the client’s
support team (for example, a job coach.)
Forensic services – Behavioral health care services provided by an order issued by the criminal or
juvenile justice system.
Behavioral Health Care Survey and Accreditation Process Guide
34
Foster care, traditional – A living arrangement where a child/youth resides outside his/her own home in
a single residence, as a means of providing protection and shelter. These living arrangements are private,
single residences, which include relative and non-relative foster homes, and non-finalized adoptive homes.
Group home – A community based, congregate living arrangement, staffed when clients are present.
Group homes may serve children, youth, or adults, capable of self-preservation in the event of an internal
disaster.
On-line behavioral health – Behavioral health care services provided through interactive, live /real time
audio and video-conferencing utilizing internet technology.
Outdoor behavioral health – Behavioral health services that use the outdoors experience as an alternative
to conventional care or treatment environments and as a clinically focused intervention.
Outpatient services – Behavioral health care organizations providing behavioral health services on an
appointment system for each visit.
Peer support – A service wherein consumers encourage other consumers in recovery.
Residential program – A program that provides 24-hour care and services to individuals who need a less
structured environment than that of an inpatient program and who are capable of self-preservation in the
event of an internal disaster. A residential setting may serve children, youth or adults.
Therapeutic foster care – Intensive treatment services provided to children or youth in a single
residence. Services are delivered primarily by treatment foster parents who bear direct responsibility for
implementing the select in-home aspects of the treatment plan.
Therapeutic schools – Day programs or 24-hour settings that provide an integrated educational milieu
with an appropriate level of structure and supervision of physical, emotional, behavioral, familial, social,
intellectual, and academic development. Therapeutic schools either grant a diploma or award credit that
leads to admission or return to a diploma-granting school. Therapeutic shcools serve children and youth
who have a history of failing to function at home or in less structured or traditional school settings in
terms of academic, social, or emotional behavioral development.
Transitional living-supervised care/supportive living – 24 hour-a-day living arrangements provided to
individuals in need of a supportive environment. This level of care is typically provided as a community
re-entry phase within a care continuum and may serve adults or older adolescents.
Vocational rehabilitation – A service or program designed to attain, retain, or restore vocational
usefulness of persons experiencing limited functioning. Vocational rehabilitation services may include
vocational evaluation services, employment skills training, work activities, and supportive employment.
Waived tests – Tests that meet the Clinical Laboratory Improvement Amendments of 1988 requirements
for waived tests; they are cleared by the Food and Drug Administration for home use and employ
methodologies that are so simple and accurate as to render the likelihood of erroneous results negligible or
pose no risk of harm to the individual tested if the test is performed incorrectly, such as: dipstick
urinalysis, glucometers, urine pregnancy testing. A certificate of waiver needs to be obtained from the
Health Care Financing Administration (HCFA) and be available for review by the surveyor(s).
0307
www.GoldSealofApproval.org
2007 Complimentary Conference Calls to
learn about Joint Commission
Behavioral Health Care Accreditation
Join us for these FREE one-hour calls to learn
important information about Joint Commission accreditation.
The calls are designed to provide information for organizations
who aren’t yet accredited by The Joint Commission.
Each call begins at noon Central time
(1pm Eastern, 11am Mountain, 10am Pacific)
August 7
The On-Site Survey Process
• What happens during a survey
• Who will the surveyors talk to
• How are the standards assessed on-site
• What materials should I have available for review
November 13
Standards Applicability – Know What Applies to You
To register, go to
www.jointcommission.org/bhcteleconference.htm
Program Summary
Tracer methodology is a process that helps organizations get a thorough look into
their care process and systems. Tracers are powerful and valuable tools when done
correctly and when focused on high risk processes within the organization. Designed
for organizations that want a better understanding of tracer implementation and
methodologies, this one-day seminar brings you the information and tools you need
to make the most of the opportunities tracers provide. Individual and Individual-
Based system tracers as well as tracer methodology and as management tool are
group discussions. At the end of this program participants will have tools and
techniques that they can take back to their organization to train tracer teams and
conduct effective tracers.
This program is essential for those in your organization who are responsible for
assessing the quality and safety of care provided throughout the organization as
well as those responsible for accreditation compliance, including survey
coordinators, risk managers, PI coordinators, department managers, and others
who have a hands-on role in the Joint Commission accreditation process, or
assessing the systems and processes within the organization.
Program Objectives
After completing this program, you will be able to:
• Understand the tracer methodology and its integral components: the indi
Behavioral Health Care: Accreditation Essentials
This seminar is designed for organizations considering accreditation, and for individuals who are new to or familiar
with accreditation. It will cover the Joint Commission’s Comprehensive Accreditation Manual for Behavioral Health
Care, the accreditation process, and unannounced surveys. Participants get detailed information about accreditation
as a systems improvement management tool, the 2007 National Patient Safety goals, the electronic Statement of
Conditions
TM
, challenging compliance issues, automation of sentinel event reporting, practical tips to improve
operational processes and maintain continuous compliance, and other Joint Commission updates. Customized
breakout sessions will cover content for providers of care, treatment and services within community-or facility-based
behavioral health care organizations. A special breakout session will cover content specifically for participants new
to the accreditation process. The seminar environment is conducive for sharing, helping and brainstorming with
others. A CD with web links and other resources is provided as part of this seminar.
After this session, you should be able to:
� Describe the key elements of the Joint Commission’s accreditation process for community-based or facility-
based behavioral health care organizations
� Explain how the standards and elements of performance apply in various community-based or facility-based
behavioral health care organizations to continuously improve the safety and quality of care provided to clients
� Discuss the five overarching areas addressed within the recovery and resiliency standards
June 26-27, 2007, Atlanta, GA (07-068)
Behavioral Health Care Update
This one-day seminar is designed for professionals that are experts on the accreditation process and standards and
works in an accredited community- or facility-based behavioral health care organization. Content will incorporate
2008 accreditation updates and tips to improve operational processes and the safety and quality of care.
November 7, 2007, Scottsdale, AZ
December 11, 2007, Chicago, IL
To register for these programs, contact JCR Customer Service at 877-223-6866 or visit www.jcrinc.com.
www.jcrinc.com
Tracer Methodology, Tracer Methodology, Tracer Methodology, Tracer Methodology,
Conducting Tracers Conducting Tracers Conducting Tracers Conducting Tracers
in Your Organizationin Your Organizationin Your Organizationin Your Organization
March 27, 2007 — Naperville, IL
www.jcrinc.com
Behavioral Health CareBehavioral Health CareBehavioral Health CareBehavioral Health Care
2007 Seminars and Conferences 2007 Seminars and Conferences 2007 Seminars and Conferences 2007 Seminars and Conferences
SAVE THE DATE!
4th Annual Joint Commission Conference on Behavioral Health Care:
Issues for Today, Actions for Tomorrow
December 12-13, 2007, Chicago, IL
An emphasis on quality care and client safety permeates the behavioral
health care field. Engaging clients and their families in a decision making
process.is a crucial factor in generating the desired outcomes of care. How
that process is conducted relies on any number of factors including the
evidence that supports the selected interventions, professional ethics that
provide a guide and framework for professional conduct in providing
services, and the availability of resources. These factors provide the
foundation for the Fourth Annual Conference on Behavioral Health Care.
The conference will address both the theoretical frameworks and the
practical application of strategies and models to improve client safety and
care and to meet the demands of accountability.
Please visit Joint Commission Resources at www.jcrinc.com for the
latest conference updates.
1
2006-2007 Comprehensive
Accreditation Manual for
Behavioral Health Care
(CAMBHC)
The 2006-2007 Comprehensive Accreditation
Manual for Behavioral Health Care (CAMBHC)
includes everything a behavioral health care
organization needs for continuous standards
compliance and operational improvement.
The 2006-2007 CAMBHC lists standards,
rationales, elements of performance (EPs),
and scoring information, and includes updated accreditation policies
and procedures information.
Each standard and EP applies specifically to behavioral health
care organizations. The CAMBHC features:
• An explanation of the unannounced survey process
• A self-assessment checklist to help organizations gauge their
compliance with standards and EPs
• National Patient Safety Goals for behavioral health care
• Standards applicability table that allows organizations to see which
standards and EPs apply to their settings, populations, programs
and services
• Standards, rationales, EPs, and scoring information for foster care
and opioid treatment programs
2006. 3-ring binder. 530 pages.
ISBN: 0-86688-944-2
ORDER BOTH the 2007 CAMBHC Core and 2007
CAMBHC Subscription Update Service as a set.
(Includes 2006 CAMBHC Subscription Update Service)
Price: $450 Order Code: CCBHC-07BQW
NEW! 2007 CAMBHC Subscription Update Service
Now Publishing Twice a Year!
This new subscription update service keeps your behavioral health
care organization up-to-date with the latest accreditation information
coming out in 2007. Updates with replacement pages for your
CAMBHC binder arrive at your door twice a year (March 2007 and
September 2007), providing you with:
• Revised and new standards, elements of performance, and
scoring
• Revised and new National Patient Safety Goals for behavioral
health care
• Revised and new accreditation policies and procedures
All new information is highlighted so you can find what you need
quickly and easily to stay on top of the latest information from
The Joint Commission.
Note: All accredited behavioral health care organizations automatically
receive one complimentary copy of the update service.
Price: $200 Order Code: CBHC-07SBQW
2006–2007 Standards for
Behavioral Health Care (SBHC)
The 2006–2007 Standards for Behavioral
Health Care (SBHC) is a 6″ x 9″, soft-cover
abridged version of the 2006–2007
CAMBHC. It also has scoring information for
all standards, including scoring categories
and measures of success (MOS).
In addition, it provides the following:
• All the standards, rationales, and elements
of performance (EPs) and scoring
• The National Patient Safety Goals specific
to behavioral health care
• Standards applicability table that allows organizations to see which
standards apply to each setting, service, program, or population
• Standards, rationales, EPs, and scoring for foster care and opioid
treatment programs
The 2006–2007 SBHC is a handy reference guide, ideally suited for
use in meetings, for orientation and training, and as a quick overview
of The Joint Commission accreditation standards for all your staff.
2006. Softcover. 510 pages.
ISBN: 0-86688-962-0
Publications
1
Joint Commission Resources
Behavioral Health Care
Product Guide
To order products, to register for seminars, or for more information, please call 1-877-223-6866 or visit our web site at www.jcrinc.com.
Price: $265
Order Code:
CBHC-06BQW
Price: $105
Order Code:
BHCS-06BQW
2
2006–2007 Accreditation
Process Guide for Behavioral
Health Care
Now includes the compliance assessment
checklist for behavioral health care!
The 2006–2007 Accreditation Process Guide
for Behavioral Health Care takes you step by
step through the who, what, when, where,
why, and how of the accreditation process,
including the most accurate information about
unannounced surveys. In addition, this easy-
to-use, spiral-bound book now includes the
handy compliance assessment checklist that
helps you get the most out of your Periodic
Performance Review (PPR), note plan(s) of
action needed, and identify areas in which
measures of success are necessary. Other
features include the following:
• A detailed explanation of the PPR process
• Tips on writing plans(s) of action and measures of success
• Standards applicability table that allows organizations to see
which standards and EPs apply to each setting, service, program,
or population
• Self-assessment questions for
all standards and elements of
performance (EPs)
• Tips on conducting tracers in
your organization
• Sample survey agendas
• Sample tracers to address priority
focus areas and clinical/service
groups
NEW! 2007 National Patient
Safety Goals Posters for
Behavioral Health Care
Need a quick reference to The Joint
Commission’s 2007 National Patient Safety
Goals for behavioral health care? Want to
educate your staff and keep those goals at
the top of their minds?
Then this poster is for you. It lists all the
2007 National Patient Safety Goals and
requirements that apply to behavioral health
care. This poster is an ideal way to
communicate the goals to staff and is a
colorful reminder that incorporating safety
into everyday activities is essential to providing excellent client care.
These posters are 8.5″ x 11″ and are printed on durable, splash-
resistant, laminated paper.
2006.
ISBN: 1-59940-041-3
NEW! How to Meet the Most
Challenging Joint Commission
Requirements for Behavioral
Health Care
In this new book, readers learn the most
common compliance challenges for all types of
behavioral health care organizations, and benefit
from strategies to meet those challenging
requirements and ensure their organizations’ continuous compliance
with Joint Commission requirements. This book discusses
challenging standards that relate to the following topics:
• Assessment processes (screening versus full assessment)
• Human resources and staffing effectiveness
• Infection control, emergency management, performance
improvement, and medication management
2006. Softcover. 166 pages.
ISBN: 1-59940-025-1
Price: $75 Order Code: MCRBH-06BQW
Issues in Human Resources
for Behavioral Health Care
Issues in Human Resources for Behavioral
Health Care is a valuable resource for any
behavioral health care organization. Providing
an in-depth look at The Joint Commission’s
Management of Human Resources (HR)
chapter in the Comprehensive Accreditation
Manual for Behavioral Health Care, this book
addresses HR challenges facing behavioral
health care organizations today. Included in
this handy reference are tools for assessing
staff competence; orienting, training, and
educating staff; and conducting peer
interviews with physicians. Special features
include:
• Complete and detailed explanations about the HR standards
• Behavioral health care-specific tips, strategies, and solutions
for overcoming human resource challenges
• Examples, forms, checklists, and case studies from actual
behavioral health care organizations
• Informative tips provided by Joint Commission surveyors
The Joint Commission’s
Unannounced Survey Process
The Joint Commission now conducts on-site
surveys on an unannounced basis. This book
provides readers with a comprehensive
overview of the unannounced survey process
and useful information to clarify what has
changed and what remains the same. You’ll
learn:
• How your organization can integrate two
key Joint Commission methodologies—the
Periodic Performance Review and tracer
methodology—with the unannounced
survey process to assist in your
improvement efforts
• How you can use strategies and examples
from other organizations that have already
experienced the unannounced survey
process
Publications
2
ELECTRONIC VERSION
Now everyone in your
organization can read a
PDF of the Accreditation
Process Guide on their PC!
Price: $545 (Site License)
Order Code:
EBAP-BH06BQW
To order products, to register for seminars, or for more information, please call 1-877-223-6866 or visit our web site at www.jcrinc.com.
Price: $119
Order Code:
BHSP-06BQW
2006. Spiral-bound.
Softcover. 375 pages.
ISBN: 0-86688-963-9
Price: $35 for a
10-pack
Order Code:
NPSGBCLP-07BQW
Price: $35
Order Code:
USB-05BQW
2006. Softcover.
90 pages.
ISBN: 0-86688-958-2
Price: $75
Order Code:
HRBHC-05BQW
2005. Softcover.
161 pages.
ISBN: 0-86688-948-5
3
A JCR Best Seller!
A Practical Guide to
Documentation in Behavioral
Health Care, Second Edition
This is your complete guide to effective
documentation practices that meet Joint
Commission behavioral health care
standards. Examples illustrate how treatment
and services across nearly every behavioral
health care setting can be improved through
better documentation practices.
Behavioral health care professionals—
including organization administrators,
department heads, program directors, clinical
staff and leaders, information management
staff, behavioral health care consultants, and those responsible for
coordinating survey preparation activities—will benefit from this
essential guide to documentation. Updated with new examples and
information!
2002. Softcover. 142 pages.
ISBN: 0-86688-778-
4
Issues in Provision of Care,
Treatment, and Services for
Behavioral Health Care
Written specifically for behavioral health care
organizations, Issues in Provision of Care,
Treatment, and Services for Behavioral
Health Care takes an in-depth look at the
Provision of Care, Treatment, and Services
(PC) standards in the Comprehensive
Accreditation Manual for Behavioral Health
Care (CAMBHC). The book provides practical
tips, examples, and case studies to assist
organizations with standards compliance. It
also focuses on the challenges of initial
screening and clinical assessment protocols,
treatment planning, and discharge assessment.
Challenging Standards for Behavioral Health
Care
This presentation focuses on standards that Joint Commission
surveyors most frequently cite as “not compliant” as well as
standards for which leaders often request consultation. Various tips
and systematic approaches for each of these challenging standards
will be discussed. The discussion includes both the CAMBHC and
applications of the hospital standards. Please call our Customer
Service Center at 877-223-6866 to register or to purchase a tape
or CD of the audio conference.
Behavioral Health Care: Accreditation Essentials
• April 26-27, 2007, Philadelphia, PA
• June 26-27, 2007, Atlanta, GA
Tracer Methodology, Conducting
Tracers in Your Organization
• April 25, 2007, South Portland, ME
• May 21, 2007, Richmond, VA
• August 16, 2007, Charleston, WV
• October 18, 2007, Scottsdale, AZ
EC Base Camp: Foundation for Environment of Care
• May 2-3, 2007, Atlanta, GA
• August 1-2, 2007, Oakbrook Terrace, IL
• October 3-4, 2007, Boston, MA
• November 5-6, 2007, Las Vegas, NV
Implementing the National Patient Safety Goals
• April 19, 2007, Naperville, IL
• October 10, 2007, Hebron, KY
A Systematic Approach to Continuous
Systems Improvement
• April 25-26, 2007, Oklahoma City, OK
• July 17-18, 2007, Oakbrook Terrace, IL
• September 11-12, 2007, Wallingford, CT
• November 5-6, 2007, Oakbrook Terrace, IL
Behavioral Health Care Update
• November 7, 2007, Phoenix, AZ
• December 11, 2007, Chicago, IL
4th Annual Joint Commission National Conference
on Behavioral Health Care: Issues for Today, Actions
for Tomorrow
• December 12-13, 2007, Chicago, IL
Plans of Action, Evidence of Standards Compliance
and Measures of Success: Putting the Pieces
Together for Continuous Compliance
• April 18, 2007, Austin, TX
• May 18, 2007, Columbus, OH
• June 5, 2007, Naperville, IL
• August 23, 2007, Scottsdale, AZ
• September 19, 2007, Newark, OH
• October 23, 2007, Oklahoma City, OK
For more details, please visit www.jcrinc.com
Restraint: Minimizing Use, Improving Outcomes
in Behavioral Health Care Settings
This video explains the restraint and seclusion standards, their
revisions, and the survey process relating to restraint use. Case
studies show psychiatric units of acute care hospitals and behavioral
health care organizations implementing innovative techniques and
approaches to minimize their use of restraint.
Price: $195 Order Code: V99/08BQW
Publications
Video
Seminars
Audio Conference
3
To order products, to register for seminars, or for more information, please call 1-877-223-6866 or visit our web site at www.jcrinc.com.
Price: $55
Order Code:
BH-500BQW
Price: $70
Order Code:
PTBHC-01BQW
2004. Softcover.
150 pages.
ISBN: 0-86688-861-6
4
Accreditation Manager Plus
To order products, to register for seminars, or for more information, please call 1-877-223-6866 or visit our web site at www.jcrinc.com.
Shared Visions–New Pathways™:
The Joint Commission’s Redesigned Process
for Behavioral Health Care
This video describes the Joint Commission’s accreditation process,
including tracer methodology, Priority Focus Process, Periodic
Performance Review, and the on-site survey process, as well as
the accreditation decision process.
Total running time: 45 minutes
Price: $275 Order Code: V0406BQW
Software
Video
Accreditation Manager Plus (AMP™): An
Interactive Toolkit for Continuous Compliance
Accreditation Manager Plus (AMP ™) software arms your
organization with everything it needs in 2007 to maintain
continuous compliance in one electronic package.
The AMP ™ includes:
• An electronic version of the Comprehensive Accreditation
Manual for Behavioral Health Care
• Ongoing assessment of compliance with standards and
elements of performance
• Detailed examples of compliance
• Essential tools for
– Project management
– Documentation
– Performance tracking
– Preparing and submitting your Periodic Performance Review (PPR)
as a team to The Joint Commission
• Updates with changes to standards requirements and the PPR
Web-based Version
• Allows multiple users to view the CAMBHC from their desk
• 24/7 access to your AMP ™ data via the Internet
• Installed on server instead of individual PCs
Enterprise Manager Plus™
Expand the benefits of using Accreditation Manager Plus (AMP™). This new tool upgrades
your AMP™ reporting capabilities, allowing you to aggregate data and produce
summary reports and graphs across multiple organizations. Compare results across
organizations or across regions. Enterprise Manager Plus™ can be installed in conjunction
with any AMP™ site license.
Accreditation Manager
Plus Webcast Training
AMP™ Basic Training
This 60-minute session helps your
organization get started with this
software tool, or even assess the
possible purchase of AMP ™.
This training session is an ideal
solution for training multiple staff
members on AMP ™.
AMP™ for Quality Managers
This 90-minute session explores
how your quality improvement
leaders can effectively use AMP ™
within your organization to
implement a system of continuous
compliance. Led by a JCR
consultant, you will learn to better
understand the capabilities of
AMP ™ and its role in ongoing
compliance.
AMP™ for IT Professionals
This 60-minute session
deconstructs the installation
process and walks your IT
professionals through the process
of correctly setting the software up
on a Network.
This session discusses the site
license version of the software only.
• 60-minute sessions are $199/per
session/per connection
• 90-minute sessions are $249/per
session/per connection
For a current schedule
or more information, go to
www.jcrinc.com/webcast.
For a listing of all AMP™ and Enterprise Manager Plus™ versions and
pricing, visit www.jcrinc.com/amp. View a demo of AMP™ by visiting
the Joint Commission Resources web site at www.jcrinc.com/amp.
Need electronic access to the behavioral health care standards?
Joint Commission Resources (JCR), an affiliate of The Joint
Commission, is the official publisher and educator of The Joint
Commission.
JCR is an expert resource for health care organizations, providing
consulting services, educational services, and publications to assist
in improving quality and safety and to help in meeting the
accreditation standards of The Joint Commission. JCR provides
consulting services independently from The Joint Commission and
in a fully confidential manner. Please visit our web site at
www.jcrinc.com.
www.jointcommission.org
A complimentary publication of
The Joint Commission
Issue Two 2007
ExecutiveDirector Behavioral health care rep appointed
to the Board of CommissionersI’m delighted to report that a well-respectedadvocate for the behavioral health care field,
New York Commissioner of Mental Health
Michael F. Hogan, Ph.D., has been
appointed as the behavioral health care field
representative to The Joint Commission’s
Board (see article on this page).
This appointment is important because it
clearly demonstrates The Joint Commission’s
commitment to the behavioral health care
field, and it provides an opportunity for
someone of Dr. Hogan’s stature to contribute
on topics of interest to the behavioral health
care field.
It is a great honor to have Dr. Hogan as an
active participant on the Board of Commis-
sioners and I anticipate his involvement will
strengthen the relationship between The Joint
Commission and the field.
For a look at current issues affecting
behavioral health care organizations, consider
attending the National Conference on
Behavioral Health Care: Issues for Today,
Actions for Tomorrow. This is the fourth year
for this gathering of the most interesting
movers, shakers, leaders and thinkers in our
field. I hope you can join us for a lively
dissection of current topics in behavioral
health care. See page 2 for registration details.
Mary Cesare-Murphy, Ph.D.
New York Commissioner of Mental
Health Michael F. Hogan, Ph.D., has
been appointed as the non-voting
behavioral health care field representa-
tive to the Board of Commissioners of
The Joint Commission.
Prior to assuming responsibilities for the
New York Office of Mental Health,
Hogan served as director of the Ohio
Department of Mental Health from
1991 to 2007. He was also chair of the
President’s New Freedom Commission
on Mental Health in 2001.
“Dr. Hogan’s expertise and in-depth
experience in the mental health arena
will enrich Board discussions on policy
issues respecting behavioral health care,”
says Dennis S. OLeary, M.D., president,
The Joint Commis-
sion. “This action
underscores the
commitment of The
Joint Commission
and its Board to all
of those in the
behavioral health
care field who are in
turn committed to
serving this vulnerable population.”
“This is an honor, and a great opportu-
nity for behavioral health,” says Hogan.
“The Joint Commission’s action in
creating this position reinforces that
behavioral health is essential for overall
health. I hope to serve our field well in
representing our concerns about good
care.”
Hogan
The Joint Commission Connect extranet site
will soon have a new look. To see what’s
in store, go to the current extranet site,
click on “What’s New” and see a sample
screen shot and read about its features.
One of the new features is that you will
be able to directly access the site by
going to www.jointcommission
connect.org. Other features to look for
include:
• Enhanced security controls to enable
organizations to apply security
settings for individuals.
Unannounced survey reminder
Beginning July 1, 2007, unannounced surveys can be conducted any-
where from 18 months to 39 months from your last survey. If you were
surveyed in January 2006, your next unannounced survey could conceiv-
ably come as early as July 2007. Check on The Joint Commission
Connect extranet by 7:30 a.m., local time, for information about Joint
Commission scheduled events.
• A “What’s Due” section that provides
an at-a-glance display of accreditation
tasks.
• A “New Reports” section that
provides an at-a-glance display of
recently posted organization reports,
such as the accreditation report.
• For corporate and multi-organization
systems, a drop down menu list will
enable the user to switch from one
organization site to another.
• A “Quicklink” to update extranet
contacts and apply security settings.
Extranet changes scheduled for June
©2007 Published by the Department of Communications, BHC Accreditation Program, Oakbrook Terrace, IL, 630-792-5790, www.jointcommission.org
Education
2007 Accreditation Essentials:
Behavioral Health Care
This program provides basic training for
any behavioral health care organization
considering accreditation. It includes
breakout sessions for addiction treat-
ment programs, children and youth
programs, and community mental health
centers.
• June 26-27, Atlanta, Ga.
ve the date!
Save the date!ave the date!
4th Annual Joint Commission
National Conference on
Behavioral Health Care Issues
• December 12-13, Chicago, Ill.
ave the date!
Publications
NEW! Issues in Human Resources
for Behavioral Health Care
Presents practical explanations and
guidance to the HR standards in the
Comprehensive Accreditation Manual
for Behavioral Health Care.
Order code: HRBHC05SJ, $75
Accreditation Process Guide for
Behavioral Health Care
Takes you step-by-step through the
entire accreditation process, includes
information to help all levels of
behavioral health care staff prepare for
the on-site survey.
Order code: BHSP06SJ, $119
How to Meet the Most Challenging
Joint Commission Requirements for
Behavioral Health Care
Order code: MCRBH-06, $75
A Practical Guide to Documentation
in Behavioral Health Care
Order code: BH500SJ, $55
Cost-effective Performance
Improvement in Behavioral Health
Care
Order code: PIBHC50SJ, $50
Merlin Wessels, associate director, Standards
Interpretation Group, answers these Frequently
Asked Questions about the Periodic Perfor-
mance Review.
What is the PPR?
The PPR is a self-evaluation that gauges
an organization’s compliance with
accreditation participation requirements,
National Patient Safety Goals, standards
and Elements of Performance. If the
organization finds areas out of compli-
ance, it develops a Plan of Action. The
organization will also identify Measures
of Success for validating the resolution
of the problem areas.
How often is the PPR completed?
Once accredited, organizations are
required to update and submit the PPR
annually. The accreditation is the due
date.
Are there different PPR options?
You can choose to do a full PPR with or
without a follow-up call to SIG; or
choose among three other options. Most
behavioral health care organizations
choose the full PPR with the call. See
www.jointcommission.org/
AccreditationPrograms/Hospitals/
AccreditationProcess/PPR_QA.htm. for a
full description of the options.
How do I begin?
The PPR is available anytime on the
Joint Commission Connect extranet.
Once your organization has completed
it, the information will be there next
Resources
For information or to order products from Joint
Commission Resources, Inc., go to
www.jcrinc.com/Infomart.htm or call
(877) 223-6866.
year. You don’t have to start from
scratch every time.
What are the common problems and
misconceptions?
Organizations think that the PPR is
punitive. It’s not. Surveyors do not have
access to the PPR; however, they will
ask about the Measures of Success
related to the findings
of the Plan of Action,
but they never see the
actual PPR.
In addition, there are
organizations that
score standards that
don’t apply and
organizations which neglect to score
standards that do apply. It’s important to
use the Standards Applicability Process
in the front of the manual to see what
standards, rationales and Elements of
Performance apply to your organiza-
tion’s setting, programs, services and
populations.
Tips for making the most of the
follow-up phone call?
• Be prepared, have questions ready
that you want addressed.
• View the time as a consultation
opportunity. The focus does not have
to be exclusively on the noncompli-
ance areas. We can help you brain-
storm and give you feedback on how
other organizations meet the stan-
dards.
Get the 411 on the PPR
Free educational conference calls are available for accredited Opioid
Treatment Programs. The sessions take place monthly from 10:30 to
noon, CST, and cover a variety of topics. The programs include:
• July 11: Behavioral Health Care Standards Review
• Aug. 15: National Patient Safety Goals
• Sept. 19: Continuous Accreditation Readiness
• Oct. 17: Standards for Recovery & Resiliency
• Nov. 21: Failure Mode Effect Analysis — A Proactive Approach to
Reducing Errors
Call Customer Service at (877) 223-6866 to register for the programs. If
you have questions, contact Megan Marx, associate director, OTP
Project, at mmarx@jointcommission.org.
Free OTP education for 2007
Table of Contents
The Joint Commission–Who Are We? 3
Joint Commission Behavioral Health Care Accreditation 3
The Standards Manual 11
Staff Directory
Peggy Lavin, LCSW, Associate Director 630-792-5411
Jasmina Juric, Specialist 630-792-5251
Susan Bullivant, Senior Secretary 630-792-5771
To request a survey 630-792-5791
Joint Commission Resources 877-223-6866
Joint Commission Resources Web Site: www.jcrinc.com
Our Surveyors — Behavioral Health Care Professionals
Our Standards Represent a National Consensus
Professional and Technical Advisory Committee
Behavioral Health Advisory Council
Eligibility for Survey
Initial Surveys
Early Survey Options (for organizations seeking accreditation but not ready for full evaluation)
Early Survey Policy
Role of the Account Representative
The Standards Manual
Medication Management
Organization Functions
National Patient Safety Goals
The On-Site Survey
Priority Focus Process
Tracer Methodology
DAY 1
Time
DAY 2
Time
DAY 3
Time
Information Needed for the Preliminary Planning Session and Survey Planning Meeting
Scoring Guidelines and Decision Rules
Survey
Notifying the Public About Accreditation
Standards Interpretation Group (SIG)
The Joint Commission Web Site
“Quality Check”
Helping You Choose..Quality Behavioral Health
Appendix B: Survey Fees
GLOSSARY
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