The Joint Commission On-Site Survey Process

1. The Joint Commission On-Site Survey Process December 7, 2010 Behavioral Health Care Accreditation Team Mary Cesare-Murphy, Ph.D. Executive Director David Wadner, PhD Field Director Peggy Lavin, LCSW Senior Associate Director Evelyn Choi, MS Senior Accreditation Specialist

2. The Joint Commission is: • Independent • Not-for-profit • Private sector, non-governmental organization • Our focus: helping behavioral health organizations help the people they serve.

3. Behavioral Health Care Accreditation Program • Accrediting behavioral health organizations since 1969. • Currently almost 1900 behavioral health care organizations are Joint Commission accredited. • Accredited organizations range from small, single service providers to very large, multiple services/programs organizations.

4. Who can become accredited under the Behavioral Health accreditation requirements? • Community-based Mental Health Services. • Services for Children and Youth. • Substance Abuse Treatment Services. • Medication Assisted Opioid Treatment Programs.

5. Addictions services Case management agencies Corrections Crisis stabilization Day programs Eating disorders treatment programs Family preservation/wraparound Forensics services Foster care In-home/community support Medication Assisted Opioid treatment Outdoor programs Outpatient programs Residential/group homes Technology-based services Therapeutic day schools Therapeutic foster care Transitional/supervised living 24-hour therapeutic schools Vocational rehabilitation Programs / Services Accredited Under Behavioral Health Care Accreditation

6. Behavioral Health Care Accreditation Standards for Specific Populations • Children and Youth • Individuals with Intellectual/Developmental Disabilities • Individuals receiving Addiction Treatment or Services • Individuals receiving Medication Assisted Treatment for Opioid Addiction

7. Behavioral Health Accreditation Program State Recognitions • 119 Distinct administrative agencies within 48 states • Examples of states recognizing accreditation: • Oklahoma • Ohio • North Carolina

8. Joint Commission Surveyors • Experienced behavioral health care professionals • Trained, mentored, and monitored to deliver consistently valuable surveys • Each surveyor surveys an average of15 times per year • Sharing good practices with you and your staff • Helping organizations in their commitment to provide safe and high quality care, treatment & services

9. “The Balancing Act” Evaluator Educator Consultant and

10. The On-site Survey Process • The on-site survey agenda is in sync with an organization’s normal operational systems • Focus is on actual delivery of care, treatment, or services -- not just paperwork • On-site survey process is customized to the setting(s), service(s) and population(s) served by the organization

11. What happens during an on-site survey? Opening Session: Orientation to the Organization • A discussion that provides an opportunity for the surveyor(s) to learn from you about your organization • What you do • Who you serve • Your staff • Your philosophy and values • How you are organized • Ensures a survey appropriate to your organization

12. Individual “Tracers” • Traces the continuum of care, treatment or services provided • Usually at least 60% of the on-site survey • Directly involves staff who provide care, treatment or services • Follows care, treatment or services provided throughout the organization • Individual served is involved if appropriate

13. Life Safety Code • Applies to 24-hour residences • Life Safety Code Categories: • Locked facilities • Lodging or Rooming Houses • 4 to 16 occupants • Hotel and Dormitories • 17 + occupants

14. Data Session • Discussion of how the organization uses data: • Identification of data to be collected • Aggregation and analysis • Use of the data for change • Performance Improvement initiatives • Annual review of data plan

15. Competence Assessment Session • Reviews the processes the organization follows to ensure that they have sufficient, competent staff • Staff selection • Verification of education and licensure • Orientation and training • Competence assessment • Performance evaluation

16. Systems Tracers Scheduled If Applicable • Medication Management • Reviews the medication processes from prescribing to administrating • Only reviews those aspects relevant to the organization • Infection Control • Reviews processes for preventing and responding to infections • Varies based on settings (e.g. facility-based vs. community-based)

17. Optional Systems Tracers • Suicide prevention • Reviews the organizations suicide prevention process • Elopement prevention • Reviews the organizations elopement procedures (where applicable) • Violence prevention • Reviews the organizations process for preventing violence within the organization

18. Daily Briefing • Start of each day after the first day • Review of the previous day’s activities • Identification of any areas of potential non-compliance with accreditation requirements • Opportunity for organization to clarify misunderstandings

19. Leadership Session • Discussion with organization leadership • Last day of survey • Based on observations during the survey • An opportunity for the leaders and surveyor to discuss how the leaders may be able to use the surveyors’ observations constructively

20. Closing Session and Report • Meeting with CEO, if desired, to review report • Meeting with staff chosen by organization • Report • Organization receives written preliminary report of any findings • Surveyor(s) provides clear explanation of survey finding(s) • Official report is provided on organization's extranet site within 2-10 days after survey

21. After your Survey • Generally 45-60 days to resolve any issues found • Work with your Account Executive • Seek advice • Account Executive primary • Standards Interpretation Group • Final Accreditation Decision posted upon resolution of findings • Don’t forget to make use of the free publicity kit posted on our web site to publicize your new status.

22. Complimentary Support to Guide you Through your First Accreditation • Behavioral Health Accreditation Team • Complimentary conference calls & webinars • Standards Interpretation Group (630) 792-5900 • Introduction to mentor organizations • Account Executives • More information at: www.jointcommission.org/BHC

23. Additional Resources Provided by Joint Commission Resources • Educational programs • Publications • Consulting services

24. Behavioral Health Care Accreditation: How to Apply for Accreditation • Request access to The Joint Commission’s electronic application for accreditation. • Indicate in the application which month during the next 12 months you would like your initial on-site survey to be scheduled. • Complete and submit the application. • Make a deposit of $1700 toward your accreditation fees.

25. What do accredited organizations say? “Joint Commission accreditation has assisted our development into a nationally recognized organization. Although Camelot has spread across many states, there is consistency in how we provide service and execute our business practices, thanks in part to our accreditation.” George Condas, PhD, Vice President Camelot for Kids, Dripping Springs, TX

26. What do accredited organizations say? “We are under constant pressure to do more with less. Joint Commission requirements are the standards we use to assure we don’t sacrifice quality or safety as we change to meet new demands. They are the center around which we organize our systems.” Susan Rushing, PhD, CEO Burke Center, Lufkin, TX

27. What do accredited organizations say? “The Joint Commission Gold Seal tells our staff, our consumers, our payors, and our contractors that we mean business, that we mean quality. That by coming to us, they can expect a standard of excellence that’s driven by an organization that is synonymous for quality not only in our country, but around the world.” Michael Flora, President and CEO Ben Gordon Center, DeKalb, IL

28. What do accredited organizations say? “I am always impressed by the experience, patience, and thoroughness of our surveyors. With The Joint Commission as a partner, I feel like we have a wise mentor prodding us to do better, to think more clearly, and to be more efficient.” Dustin Tibbitts, Executive Director InnerChange New Haven, Provo, UT

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

30. Behavioral Health Care Accreditation Team Mary Cesare-Murphy, PhD Executive Director mcesaremurphy@jointcommission.org 630/792-5790 David Wadner, PhD Field Director dwadner@jointcommission.org 630/792-5788 Peggy Lavin, LCSW Senior Associate Director plavin@jointcommission.org 630/792-5411 Evelyn Choi, MS Senior Accreditation Specialist echoi@jointcommission.org 630/792-5866