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.pdf (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.pdf (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.pdf (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
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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 …