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Behavioral Health Care Accreditation Team
Mary Cesare-Murphy, Ph.D.Executive Director
David Wadner, PhDField Director
Peggy Lavin, LCSWSenior Associate Director
Evelyn Choi, MSSenior Accreditation Specialist
The Joint Commission
On-Site Survey Process
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The Joint Commission is:
Independent
Not-for-profit
Private sector, non-governmental organization
Our focus: helping behavioral health organizations help the people they serve.
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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.
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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.
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Programs / Services Accredited
Under Behavioral Health Care Accreditation
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
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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
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Behavioral Health Accreditation Program
State Recognitions
119 Distinct administrative agencies within 48 states
Examples of states recognizing accreditation:– Oklahoma– Ohio– North Carolina
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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
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“The Balancing Act”
Evaluator EducatorConsultant
and
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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
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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
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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
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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
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Data Session
Discussion of how the organization uses data:
– Identification of data to be collected
– Aggregation and analysis
– Use of the data for change
– Performance Improvement initiatives
– Annual review of data plan
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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
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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)
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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
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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
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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
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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
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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.
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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
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Additional Resources Provided by
Joint Commission Resources
Educational programs Publications Consulting services
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Behavioral Health Care Accreditation:
How to Apply for Accreditation
1. Request access to The Joint Commission’s electronic application for accreditation.
2. Indicate in the application which month during the next 12 months you would like your initial on-site survey to be scheduled.
3. Complete and submit the application.
4. Make a deposit of $1700 toward your accreditation fees.
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“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
What do accredited organizations say?
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“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
What do accredited organizations say?
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“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 CEOBen Gordon Center, DeKalb, IL
What do accredited organizations say?
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“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
What do accredited organizations say?
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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.
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Behavioral Health Care Accreditation Team
Mary Cesare-Murphy, PhDExecutive Director
[email protected] 630/792-5790
David Wadner, PhDField Director
[email protected]/792-5788
Peggy Lavin, LCSWSenior Associate [email protected]
630/792-5411
Evelyn Choi, MSSenior Accreditation Specialist
[email protected]/792-5866
