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Comprehensive Accreditation Manual for Behavioral Health Care and Human Services Effective January 1, 2022
Standards
Elements of Performance
Accreditation Policies and Procedures
2022 CAMBHC Comprehensive ComprehensiveAccreditation Accreditation Comprehensive Accreditation Manual for Behavioral Health Care and Human Services (PDF manual) What’sNew 2022CAMBHC Standardsandelementsofperformance(EPs)publishedinthismanualareeffectiveasof January1,2022.
Note: Note: Yourorganizationisresponsibleformeetingallapplicablechangestoaccreditation requirementsfororganizationsaccreditedundertheBehavioralHealthCareandHuman ServicesProgrampublishedin TheJointCommissionPerspectives®,theofficialmonthly newsletterofTheJointCommission.
Majorchangestorequirements,accreditationpoliciesandprocedures,andother importantinformationincludethefollowing:
Removedtheterm on-site asitrelatestosurveyactivitiesthroughoutthemanualin responsetopandemic-relatedchangestothesurvey/reviewprocess
Revisedstandardscross-referencesthroughoutthemanual
Reorganizedcontentthroughoutthe“SafetySystemsforIndividualsServed”(SSIS) chaptertoclarifyconceptsrelatedtosafetyandalignwiththerevised“Sentinel EventPolicy”(SE)chapter. There Therearearenononewnewrequirements,requirements,onlyonlyclarifications. clarifications. RemovedrequirementsandEPsfromthe“AccreditationParticipationRequirements”(APR)chapterrelatedtoFocusedStandardsAssessment
AddedandrevisedLeadershipandPerformanceImprovementrequirements requiringaperformanceimprovementplan
Revised“LifeSafety”(LS)requirements,includingaddingnewrequirementsfor organizationsthataredefinedasbusinessoccupancies,addingnewstandardsrelated tomitigatingfireandsmokehazardsandevents,andrevisingrequirementsfor sprinklerheads
Renamedthe“SentinelEvents”(SE)chapterto“SentinelEventPolicy”(SE)and revisedtoimprovetheflowandunderstandingofthepolicyandtoclarify expectationsregardingahealthcareorganization’spartnershipandcollaboration withtheOfficeofQualityandPatientSafety,asdescribedintheJuly2021issueof TheJointCommissionPerspectives. There Therearearenononewnewdefinitions,definitions,expectations,expectations,or or changes changestotosentinelsentineleventeventreportingreportingprocesses,processes,onlyonlyclarifications. clarifications.
Comprehensive Accreditation Manual for Bahavioral Health Care and Human Services (PDF manual)
Revisedgender-identifyingcontenttogenderneutralthroughoutthemanualto encompassallgenderidentities
Introduction:HowJointCommissionAccreditationCanHelpontheRoadto HighReliability(INTRO)
EffectiveJuly1,2021
Mademinoreditorialchanges
EffectiveJanuary1,2022
Introduction:HowJointCommissionAccreditationCanHelpontheRoadto HighReliability:Changedtitle;addedtextexplainingwhathighreliabilityinhealth caremeans
Figure2:Updatedtoincludecurrentmanualexample
Figure4:UpdatedtoincludeupdatedE-ditionscreenshot
StimulateImprovement:UpdatedCenterforTransformingHealthCarebulletto highlightavailabletools,includingtheTargetedSolutionsTool®andtheOro®2.0 HighReliabilityOrganizationalAssessment
Mademinoreditorialchanges
SafetySystemsforIndividualsServed(SSIS) EffectiveJuly1,2021
Mademinoreditorialchanges
EffectiveJanuary1,2022
Reorganizedcontentthroughoutthechaptertoclarifyconceptsrelatedtosafetyof theindividualserved
AddedreferencestoappropriatecontentinthemanualorE-ditionforfurther information
Introduction:ChangedsectiontitletoQualityandSafetyinCare,Treatment,and Servicestobetterdescribesectioncontents
Sidebar1:Madethefollowingchanges:
Addedafootnotethatclarifiesuseofthecommonterm patientsafetyevent acrossaccreditationprograms
Clarifiedthedefinitionof sentinelevent toaddressharm,regardlessofits durationorseverity
Clarifiedthedefinitionofa closecall tonoteitposesariskofharm
Comprehensive Accreditation Manual for Bahavioral Health Care and Human Services (PDF manual) WhatDoesThisChapterContain?:Madethefollowingchanges: ChangedsectiontitletoGoalsofThisChapter
ModifiedlanguagetoemphasizetherelationshipbetweenJointCommission accreditationandpatientsafety
Alignedchapterobjectivestomatchrevisedchapter
BecomingaLearningOrganization:Madethefollowingchanges: Addedtexttohighlighttheimportanceofanalyzingsafetyevents(inaddition toreportingthem)withacomprehensivesystematicanalysis
Addedacross-referencetothe“SentinelEventPolicy”(SE)chapter
TheRoleofLeadersinPatientSafety:Madethefollowingchanges: Slightlytweakedtitleofthissection
AdjustedSidebar2:Revisedtodelineateindividualaccountabilityfrom organizationaccountability
DataUseandReportingSystems:Madethefollowingchanges: Adjustedwordingtoencouragestafftoidentifyandreportpatientsafetyevents Table1:Removedexamplechartsandreplacedthemwithdefinitionsofthe tools
AProactiveApproachtoPreventingHarm:Madethefollowingchanges: Revisedthelistofsystemsandprocessesthatshouldbeanalyzedinaproactive approachtohazardousconditions,includingprovidingexamplesof inadequate staffinglevels
Updatedthelistoftoolsavailablethatorganizationscanusetoperformsafety self-assessments
EncouragingPatientActivation:Addedlanguagetoencouragetransparentcommunicationwhenharmdoesoccur
BeyondAccreditation:TheJointCommissionIsYourPatientSafetyPartner: UpdatedthelistofJointCommissionresources
References:Updatedtomatchrevisedandreflowedchapter
Appendix:Removedthelistingofapplicablestandardstoreduceduplicationinthe manual
Mademinoreditorialchanges
Comprehensive Accreditation Manual for Bahavioral Health Care and Human Services (PDF manual) AccreditationRequirements
AccreditationParticipationRequirements(APR)
EffectiveJuly1,2021
APR.03.01.01:DeletedstandardanditsEPs
APR.06.01.01:RemovedNoteaboutconsultingservices
Mademinoreditorialchanges
EffectiveJanuary1,2022
Mademinoreditorialchanges
Care,Treatment,andServices(CTS)
EffectiveJanuary1,2022
Revisedstandardscross-reference(s)inthefollowingrequirements:
StandardCTS.02.01.05andEP4
StandardCTS.02.01.06
CTS.04.02.25,EP2
Removedstandardscross-reference(s)fromthefollowingrequirements: StandardCTS.02.01.07
CTS.02.01.09,EP1
CTS.02.03.03,EP2
CTS.02.03.05,EPs3and4
CTS.06.02.03,EP9
CTS.02.01.07,EP2:Addedstandardscross-reference
CTS.02.02.01:Madethefollowingchanges: NewEP1:RenumberedformerCTS.02.02.03,EP1
EPs1–8:RenumberedasEPs2–9
CTS.02.02.03:Madethefollowingchanges: Standard:Deleted
EP1:RenumberedasCTS.02.02.01,EP1,andrevised EP3:RenumberedasCTS.03.01.01,EP1,andrevised EP4:Deletedrequirement
CTS.03.01.01:Madethefollowingchanges:
EP1:Deleted
EP3:CombinedwithandrenumberedasCTS.03.01.03,EP3
Comprehensive Accreditation Manual for Bahavioral Health Care and Human Services (PDF manual) CTS.03.01.03,EP3:CombinedwithCTS.03.01.01,EP3;removedstandards cross-reference
Mademinoreditorialchanges
EnvironmentofCare(EC)
EffectiveJuly1,2021
EC.02.03.03,EP1:AddedNotetoclarifywhenbehavioralhealthcarefacilitiesare consideredahealthcareoccupancy
EC.02.03.03,newEP6:Addednewrequirementforconductingfiredrillsin residentialboardandcarefacilities,andaddedDocumentationicon
EC.02.05.03,EP1:Clarifiedrequirementsforelectricalsystems,andadded referenceforadditionalguidance
Mademinoreditorialchanges
EffectiveJanuary1,2022
Revisedstandardscross-reference(s)inthefollowingrequirements:
EC.02.01.01,EP11
EC.02.02.01,EP2
Mademinoreditorialchanges
EmergencyManagement(EM)
EffectiveJanuary1,2022
Removedstandardscross-reference(s)fromthefollowingrequirements: StandardEM.02.01.01andEP2
EM.02.02.03,EP12
EM.02.02.11,EP1
EM.03.01.03,EP5
Mademinoreditorialchanges
HumanResourcesManagement(HRM)
EffectiveJuly1,2021
OverviewforHumanResourcesManagement:Revisedtoincludesummaryofthe WHO’sGlobalStrategyonHumanResourcesforHealth:Workforce2030 Mademinoreditorialchanges
Comprehensive Accreditation Manual for Bahavioral Health Care and Human Services (PDF manual) EffectiveJanuary1,2022
Revisedstandardscross-reference(s)inthefollowingrequirements:
HRM.01.03.01,EP3
HRM.01.06.05,EP2
HRM.01.07.01,EP3
Mademinoreditorialchanges
InfectionPreventionandControl(IC)
EffectiveJuly1,2021
Mademinoreditorialchanges
EffectiveJanuary1,2022
Removedstandardscross-reference(s)fromthefollowingrequirements:
IC.01.05.01,EP6
IC.02.01.01,EPs6and7
Mademinoreditorialchanges
InformationManagement(IM)
EffectiveJuly1,2021
Mademinoreditorialchanges
EffectiveJanuary1,2022
StandardIM.02.01.01,Introduction:Clarifiedlanguagerelatedtotheprivacy, security,andconfidentialityofhealthinformation
Mademinoreditorialchanges
Leadership(LD)
EffectiveJuly1,2021
Mademinoreditorialchanges
EffectiveJanuary1,2022
LD.03.07.01:CombinedwithPI.01.01.01,EP1;revisedstandardscross-references
Mademinoreditorialchanges
Comprehensive Accreditation Manual for Bahavioral Health Care and Human Services (PDF manual) LifeSafety(LS) EffectiveJuly1,2021
OverviewandAboutThisChapterforLifeSafety:Addedinformationfor organizationsthataredefinedasbusinessoccupancies,andclarifiedrequirements fordifferentoccupancytypes
LS.04.01.20:Madethefollowingchanges:
EP2:AddedNotetoexplainthatoutsidewindowscanserveasthesecondary meansofescape
EP3:Deletedrequirement
EP4:Revisedtoclarifywidthrequirementfordoorsandpathsoftraveltoa meansofescapefornewandexistingconstruction
EP6:Revisedtoincludeexceptionsforstairenclosures
LS.04.01.30:Madethefollowingchanges:
EPs1and2:AddedNotetorefertoLS.04.01.20,EP6,forstairenclosure requirements
EP3:Revisedtoexplainclassratingsforexistingwallandceilinginterior finishes
EP4:Revisedtoclarifyfirealarmsystemrequirementsfornewandexisting buildings
EP6:Revisedtospecifysmokealarmrequirementsforsleepingroomsinnew andexistingunsprinkleredbuildings
EP7:Addedsolidcorewooddoorasoptionforsleepingrooms
LS.04.02.20:Madethefollowingchanges:
EP1:Revisedtoclarifyrequirementforfire-ratedwallsandenclosuresin interiorexitstairways
EP10:Revisedtospecifyemergencylightingrequirementsfornewandexisting buildings
EPs11and12:CombinedandrenumberedasLS.04.02.20,EP11
LS.04.02.30:Madethefollowingchanges:
EP1:Addedrequirementforunprotectedverticalopeningsinexisting sprinkleredbuildings
EP3:Updatedlistofbuildingareastoassesstoidentifydeficientareas
Comprehensive Accreditation Manual for Bahavioral Health Care and Human Services (PDF manual) EP4:Revisedtoexplainclassratingsforexistingwallandceilinginterior finishes
EP7:Revisedtoclarifysmokealarmrequirementsinsleepingroomsinexisting facilities
EP10:Revisedtoclarifyfire-ratingrequirementsforcorridorwallsinnew buildings
EP11:Revisedtoclarifyfire-ratingrequirementsforcorridorwallsinexisting buildings
EP12:Addedsolidcorewooddoorasoptionfordoorsopeningtoexitaccess corridors
EP16:Revisedtoclarifysmokecompartmentsizesonsleepingroomfloorsin newandexistingbuildings
NewStandardLS.05.01.10andEPs1–7:Addedrequirementsaboutminimizing theeffectsoffire,smoke,andheatinbehavioralhealthcarefacilitiesthatare businessoccupancies
NewStandardLS.05.01.20andEPs1–9:Addedrequirementsaboutmaintaining theintegrityofthemeansofegressinbehavioralhealthcarefacilitiesthatare businessoccupancies
NewStandardLS.05.01.30andEPs1–4:Addedrequirementsaboutmaintaining buildingfeaturestoprotectindividualsfromfireandsmokehazardsinbehavioral healthcarefacilitiesthatarebusinessoccupancies
NewStandardLS.05.01.34andEPs1–3:Addedrequirementsaboutprovidingand maintainingfirealarmsystemsinbehavioralhealthcarefacilitiesthatarebusiness occupancies
NewStandardLS.05.01.35andEPs1–6:Addedrequirementsaboutprovidingand maintainingfireextinguishingequipmentinbehavioralhealthcarefacilitiesthatare businessoccupancies
Mademinoreditorialchanges
EffectiveJanuary1,2022
LS.02.01.35,EP7:RevisedrequirementandaddedNotetoexplainincremental increaseforsprinklerheadrequirement
Mademinoreditorialchanges
MedicationManagement(MM)
EffectiveJuly1,2021
Mademinoreditorialchanges
EffectiveJanuary1,2022
Removedstandardscross-reference(s)fromthefollowingrequirements:
MM.01.01.03,EP1
MM.05.01.07,EP3
Revisedstandardscross-reference(s)inthefollowingrequirements:
MM.03.01.05,EP2
MM.06.01.01,EP3
MM.08.01.01,EP6
Mademinoreditorialchanges
NationalPatientSafetyGoals(NPSG) EffectiveJuly1,2021
Mademinoreditorialchanges
EffectiveJanuary1,2022
Mademinoreditorialchanges
PerformanceImprovement(PI)
EffectiveJanuary1,2022
ChapterOutline:Updatedtoalignwithstandardschanges
PI.01.01.01:Madethefollowingchanges:
EP1:CombinedwithandrenumberedasLD.03.07.01,EP2 EPs12,13,27–29,31,and36:AddedDocumentationicon
EP30:Removedstandardscross-reference
StandardPI.02.01.01:Madethefollowingchanges: AddednewStandard,Rationale,andEPs1and2(withDocumentationicons) requiringanorganizationtohaveaperformanceimprovementplan RenumberedpreviousrequirementandEPs4,8,and9asStandard PI.03.01.01,EPs4,8,and9
StandardPI.03.01.01:RenumberedformerStandardandEPs2,4,and11as StandardPI.04.01.01,EPs2,5,and11,respectively
Comprehensive Accreditation Manual for Bahavioral Health Care and Human Services (PDF manual) StandardPI.04.01.01:AddednewRationaletoexplainimportanceofdatain performanceimprovementandnewEP3touseimprovementtoolsormethodologiestoimproveperformance
Mademinoreditorialchanges
RecordofCare,Treatment,andServices(RC)
EffectiveJanuary1,2022
RC.02.01.01,EP25:Removedstandardscross-reference Mademinoreditorialchanges
RightsandResponsibilitiesoftheIndividual(RI)
EffectiveJuly1,2021
Mademinoreditorialchanges
EffectiveJanuary1,2022
RI.01.04.03,EP6:Revisedstandardscross-reference RI.01.05.01,EP10:Addedstandardscross-reference Mademinoreditorialchanges
WaivedTesting(WT)
EffectiveJanuary1,2022
Mademinoreditorialchanges
AccreditationProcessInformation
TheAccreditationProcess(ACC)
EffectiveJuly1,2021
ClarifiedthatacceptableEvidenceofStandardsComplianceisrequiredwithin 60 calendar days
AccreditationProgram–SpecificTracers:Updatedfostercare–relatedcontentto includechildwelfare–inclusivelanguage
RiskAreas:Addedtwopotentialriskareassurveyorsmayexplore SurveyAgenda:Updatedlinkto SurveyActivityGuide IntracycleMonitoring(ICM):ClarifiedthatcompletionoftheICMProfileis optional,exceptfororganizationsissuedaPDA02decision
DecisionRulesforOrganizationsSeekingReaccreditation:Clarifiedwhyan organizationwouldearnaDA06decision
Mademinoreditorialchanges
EffectiveJanuary1,2022
MultiorganizationOption:Addedtabletoillustratesurveyprocessoptions
PublicInformationPolicy:Removedpolicyandreplacedwithasummarythat includesalinktothefullpolicytext
SurveyAgenda:RevisedSurveyorTeamMeeting/PlanningSessiontoSurveyor Planning/TeamMeetingtoalignwith SurveyActivityGuide Mademinoreditorialrevisions
StandardsApplicabilityProcess(SAP) EffectiveJuly1,2021
Added,deleted,andrevisedapplicabilityselectionstoalignwithstandardschanges, aspreviouslyidentified
EffectiveJanuary1,2022
Added,deleted,andrevisedapplicabilityselectionstoalignwithstandardschanges, aspreviouslyidentified
SentinelEventPolicy(SE) EffectiveJuly1,2021
Sentineleventdefinition:Refinedtheprevioustwobulletsaddressingrape,assault, andhomicideintosixrevisedbulletsseparatelyaddressingsexualabuse/assault, physicalassault,andhomicideofanypatientorstaffmember,licensedindependent practitioner,visitor,orvendor Mademinoreditorialchanges
EffectiveJanuary1,2022
Renamedthechapter“SentinelEventPolicy”(SE)
Reorganizedcontentinthepolicytoflowinamorelogicalorderandconnect relatedcontent
Simplifiedandclarifiedlanguagewhenpossibletoincreaseunderstandingofthe policy
Reducedduplicativecontentthroughoutthechapter
Movedthedefinitionsofanytermshownin boldface boldfaceandanditalics italics inthedescription ofsentineleventintonewSidebar1toallowforabetterunderstandingofkeyterms andhelporganizationsbetternavigatetherequirementsinthepolicy
Strengthenedthedescriptionofanaccreditedorganization’srequiredresponsetoa sentinelevent
AddednewFigure1,whichprovidesageneraltimelineofthesentinelevent responseprocess
CreatednewTable1tohelporganizationsbetterunderstandtheiroptionsfora JointCommissionreviewofanorganization’sresponsetoasentinelevent
UpdatedthedescriptionofTheJointCommission’sresponsewhenitbecomes awareofasentinelevent
RemovedtheAppendixofapplicablestandardstoreduceduplicationinthemanual. Applicablestandardsarestillreferencedwithinthepolicy
TheJointCommissionQualityReport(QR) EffectiveJanuary1,2022
CanMyBehavioralHealthCareandHumanServicesOrganizationCommenton ItsQualityReport?:Revisedcommentarymaximumfromtwopagesto5,000 characters
Mademinoreditorialchanges
RequiredWrittenDocumentation(RWD)
EffectiveJuly1,2021
Updatedtoalignwithstandardschanges,aspreviouslyidentified
EffectiveJanuary1,2022
Updatedtoalignwithstandardschanges,aspreviouslyidentified
EarlySurveyPolicy(ESP) EffectiveJuly1,2021
Updatedtoalignwithstandardschanges,aspreviouslyidentified
EffectiveJanuary1,2022
RemovedPI.01.01.01,EP1
Accreditation Manual for Bahavioral Health Care and Human Services (PDF manual)
OpioidTreatmentPrograms(OTP)
EffectiveJuly1,2021
Updatedtoalignwithstandardschanges,aspreviouslyidentified Mademinoreditorialchanges
EffectiveJanuary1,2022
Updatedtoalignwithstandardschanges,aspreviouslyidentified
ChildWelfare(CW) EffectiveJanuary1,2022
Updatedtoalignwithstandardschanges,aspreviouslyidentified
BehavioralHealthHome(BHH)
EffectiveJanuary1,2022
Updatedtoalignwithstandardschanges,aspreviouslyidentified
Glossary
EffectiveJuly1,2021 Mademinoreditorialchanges
EffectiveJanuary1,2022 Mademinoreditorialchanges
Index(IX)
The Joint Commission Mission The mission of The Joint Commission is to continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value.
© 2022 The Joint Commission Published by Joint Commission Resources
Oak Brook, Illinois 60523 USA
https://www.jcrinc.com
Joint Commission Resources, Inc. (JCR), a not-for-profit affiliate of The Joint Commission, has been designated by The Joint Commission to publish publications and multimedia products. JCR reproduces and distributes these materials under license from The Joint Commission.
JCR educational programs and publications support, but are separate from, the accreditation activities of The Joint Commission. Attendees at JCR educational programs and purchasers of JCR publications receive no special consideration or treatment in, or confidential information about, the accreditation process.
All rights reserved. No part of this publication may be reproduced in any form or by any means without written permission from the publisher. Requests for permission to make copies of any part of this work should be sent to permissions@jcrinc.com.
ISBN: 978-1-63585-237-0
For more information about The Joint Commission, please visit https://www.jointcommission.org.
This PDF manual matches the hard-copy 2022 Comprehensive Accreditation Manual for Behavioral Health Care and Human Services (CAMBHC). There may be blank pages due to revisions made through the CAMBHC Subscription Update Service.
This PDF manual matches the hard-copy 2022 Comprehensive Accreditation Manual for Behavioral Health Care and Human Services (CAMBHC). There may be blank pages due to revisions made through the CAMBHC Subscription Update Service.
Introduction:HowJoint CommissionAccreditationCan HelpontheRoadtoHigh Reliability(INTRO) Highreliabilityinhealthcaremeansmaintainingconsistentlystronglevelsofsafetyand qualityovertimeandacrossallhealthcareservicesandsettings.Highreliability organizationsoperateincomplex,high-hazarddomainsforextendedperiodswithout seriousaccidentsorcatastrophicfailures.Beginningahighreliabilityjourneycanfeel overwhelming—butitdoesn’thavetobe.Workingwiththerightpartnercanhelp optimizefocusandcreateamoreproductiveexperience.JointCommissionaccreditation representsacriticalstepinanyhealthcareorganization'son-goingjourneytowardzero harmthroughhighreliability.Itprovidestoolsandbestpracticebenchmarkstohelp sustainandelevatethequalityandsafetyofcare,treatment,andservicesprovided.
This“Introduction:HowJointCommissionAccreditationCanHelpontheRoadto HighReliability”(INTRO)chapterisanintroductiontoJointCommissionaccreditationandauser’sguidetounderstandinghowthe ComprehensiveAccreditationManual forBehavioralHealthCareandHumanServices (CAMBHC)anditsE-dition® counterpartareorganized.(TheE-ditionisaweb-basedandfullysearchableelectronic manualaccessiblethroughyourprogram’s JointCommissionConnect®extranetsite.)
Therearefourpartsinthisintroductiontoguideyoutowardcomplianceandsupport yourjourneytohighreliability:
1. PartIprovidesabriefoverviewofthevalueofJointCommissionaccreditation,the BehavioralHealthCareandHumanServicesAccreditationProgram,andits certificationoption.
2. PartIIexplainstheorganizationandcontentofthe CAMBHC.
3. PartIIIexplainshowyoucanusethe CAMBHC tosuccessfullyachieveandmaintain compliancewithJointCommissionstandards.PartIIIalsoprovidestipsand strategiesforfindingtheinformationyouneedtostaycurrentwithJoint Commissionstandardsandunderstandthesurveyprocess.
4. PartIVprovidesacomprehensivelistofcontactsandresourcesyoucanusetoget moreinformationatTheJointCommissionandJointCommissionResources.
ReadthischapterfirsttounderstandtheBehavioralHealthCareandHumanServices AccreditationProgramandthestructureandcontentofthe CAMBHC.Afteryouhavea betterunderstandingofthevalueofaccreditationinimprovingandmaintainingthe qualityofcare,treatment,orservices,maximizingthesafetyoftheindividualserved, andstimulatingperformanceimprovement,read“TheAccreditationProcess”(ACC) chaptertounderstandtheJointCommission’saccreditationprocess,includingeligibility foraccreditation;theapplicationprocess;accreditationsurveysandwhattoexpect before,during,after,andbetweensurveys;accreditationdecisionrules;andreviewand appealprocedures.
I.IntroductiontoJointCommission Accreditation TheValueofJointCommissionAccreditation TheJointCommission’sGoldSealofApproval®isawidelyrecognizedbenchmark representingthemostcomprehensiveevaluationprocessinthehealthcareindustry.
JointCommissionaccreditationbenefitsyourorganizationinthefollowingways: Givesyouacompetitiveadvantage: Achievingaccreditationandspecialtycertification isavisibledemonstrationtoindividualsservedandthecommunitythatyour organizationiscommittedtoprovidingthehighestqualityofcare,treatment,or services.Italsosetsyouapartfromotherorganizationsofferingthesametypesof care,treatment,orservices.
Assistswithrecognitionfrominsurers,associations,andotherthirdparties: Many payers,regulatoryagencies,governmentagencies,andmanagedcarecontractors requireJointCommissionaccreditationforreimbursement,forcertificationor licensure,andasakeyelementoftheirparticipationagreementsandreimbursement practices.
Helpsorganizeandstrengthenperformanceimprovementefforts: Accreditationencompassesstate-of-the-artperformanceimprovementconceptsthathelpyou continuouslyimprovequalityandstandardizeyourprocessesofcare,treatment,or services.
Helpsorganizationsbecomehighreliabilityorganizations: TheJointCommission offersnumerousresourcesandinformationtohelpbehavioralhealthcareand humanservicesorganizationsmovetowardhighreliability—thatis,toconsistently performathighlevelsofqualityandsafetyacrossallservicesandtomaintainthese levelsoverlongperiods.Theseresourceshelpleadershipcommittohighreliability
Introduction:HowJointCommissionAccreditationCanHelpontheRoadtoHighReliability bymakingitapriority,establishingasafetyculturethroughouttheorganization thatemphasizestrustandthereportingofunsafeconditionsandopportunitiesfor improvement.TheJointCommissionalsoencouragesbehavioralhealthcareand humanservicesorganizationstouseRobustProcessImprovement®(RPI®)toolsand methodologies(suchasLean,SixSigma,andchangemanagement)tosystematically improveprocessesandavoidcommon,crucialprocessfailures.
Enhancesstaffeducation: Theaccreditationprocessisdesignedtobeeducational. JointCommissionsurveyorssharebestpracticeapproachesandstrategiesthatmay helpyourorganizationbettermeettheintentofthestandardsand,moreimportant, improveperformanceofday-to-dayoperations.
Providesaccesstoexpertsinqualityandsafety: TheJointCommissioniscommittedto helpingyourbehavioralhealthcareandhumanservicesorganizationmovetoward highlyreliablecare,treatment,orservices.ThroughTheJointCommission,your organizationhasaccesstoarangeofprofessionalseagertoseeyousucceed.Itstarts withtheassignmentofanaccountexecutivespecializinginbehavioralhealthcare and/orhumanservicestohelpinday-to-dayaccreditationactivities.Youalsohave readyaccesstotheclinicalorengineeringexpertsinourStandardsInterpretation Group(SIG)aswellascliniciansurveyorswhovisityourorganizationforsurveys andclinicianswhoareavailabletohelpprovideexpertanalysisofsentineleventsin theOfficeofQualityandPatientSafety.
Figure1illustrateshowJointCommissionaccreditationguidesorganizationsin achieving,maintaining,anddemonstratingconsistentexcellenceinqualityandsafety. PartIIIofthischapter(StepstoAchievingandMaintainingCompliance)provides additionaldetailonothertoolsandresourcesavailabletoaccreditedorganizations.
Achieve, Maintain, and Demonstrate Consistent Excellence An Overview of the Joint Commission’s Accreditation and Specialty Certification Process
Nationally Recognized Standards
• Enhanced requirements address critical patient safety and overall quality issues for individuals served, including staff competency, medication management, infection control, and education for individuals served and their family
• Process-focused elements of performance provide a comprehensive foundation for quality and safety
• Optional Behavioral Health Home Certification requirements raise the bar for excellence and distinguish advanced competencies
Tools & Resources
• The Center for Transforming Healthcare and its Targeted Solutions Tool™ provide interactive tools that help accredited organizations move toward high reliability and address challenging areas such as infection control and hand-off communication
• Survey Activity Guide outlines the activities of a survey and helps an organization prepare for survey
On- and Off-Site Evaluations
• Patient/resident and system tracers proactively identify risks and high-performing areas
• Experienced surveyors share leading practices and insights to help you address challenging areas
• Survey provides a collaborative learning environment for leadership and staff
Intracycle Monitoring
• Intracycle Monitoring process guides and supports your ongoing quality improvement efforts
• Organizations in the Sustaining Improvement Program (those that have received a decision of Preliminary Denial of Accreditation PDA02) are required to participate, at the 12th month after their survey, in a dedicated consultative call (TouchPoint) with the Standards Interpretation Group
Figure Figure1. 1. TheJointCommission’sBehavioralHealthCareandHumanServicesAccreditationProgramis designedtohelpeligibleorganizationsachieve,maintain,anddemonstrateconsistentexcellenceintheservices theyprovidetoindividualsserved.Theprogramhasseveralkeycomponentsdesignedtoworkcollectivelyto betterpoweryouroverallperformanceimprovementefforts.
JointCommissionAccreditation TheJointCommission’sBehavioralHealthCareandHumanServicesAccreditation Programusesaperson-centeredqualityframeworkandcollaborativeapproachtohelp organizationsproactivelyidentifyandaddressvulnerabilitiestosafeguardindividuals served.
AddressingComplexBehavioralHealthand HumanServicesAccreditation-RelatedIssues Therearemanyfactorsthataffectoutcomesexperiencedbytheindividualsservedin behavioralhealthcareandhumanservicesorganizations.Forexample,asufficient numberofstaffmemberstosupporttheneedsofanindividualservedwillhelpprevent adverseoutcomessuchastrauma,abuse,neglect,andexploitation,andharmtoselfand others.Likewise,havingeducated,competent,andproperlytrainedstaffpositively impactstheorganization’sabilitytoassess,plan,anddeliversafe,high-qualitycare, treatment,orservicestoitsindividualsserved.
Researchshowsthatsomeofthegreatestchallengesforbehavioralhealthcareand humanservicesorganizationsareaddressingcomplexissuesaffectingindividualsserved, suchasahistoryoftrauma,abuse,neglect,and/orexploitation;challengingbehaviors; physicalholdingofachildoryouth;andavoidingrestraint/seclusion.Staffand leadershiparestrivingtoincorporateperson-centeredcare,treatment,orservices.
TheBehavioralHealthCareandHumanServicesAccreditationProgramhelpsproviders achieve,maintain,anddemonstrateconsistentexcellenceintheservicestheyprovide. ThestandardsspecificallylistedinTable1canhelporganizationsbegintodevelop strategiestoaddressthemostchallengingandcomplexissuesaffectingindividuals served.
Note: Note: Table1doesnotaddressalloftheaccreditation-relatedissuesfacingleadersin behavioralhealthcareandhumanservicesorganizations.Challengesmaydifferdependingon thesettingandpopulationtheorganizationserves,aswellastheservicesprovided.
CTS.02.02.05
RI.01.06.03
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RI.01.06.03
CTS.05.05.01
CTS.05.05.03
CTS.05.05.05
CTS.05.05.07
CTS.05.05.09
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CTS.05.05.15
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CTS.01.03.01
CTS.02.01.01
NPSG.15.01.01
CTS.05.06.01
CTS.05.06.03
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CTS.05.06.07
CTS.05.06.09
CTS.05.06.11
CTS.01.03.01
CTS.02.01.01
CTS.02.02.01
APR.09.01.01
APR.09.02.01
HRM.01.04.01
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LD.03.02.01
LD.03.03.01
LD.03.04.01
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LD.03.09.01
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LD.03.06.01
Followingthedirectionprovidedinthesestandardsandfocusingontheindividual servedwillallowstafftobegintoexplorewaystoimprovecare,treatment,orservicesto helpindividualsservedinattainingthemostfavorableoutcomespossible.AselfassessmentusingtheIntracycleMonitoring(ICM)process(discussedinmoredetailin “TheAccreditationProcess”[ACC]chapter)andtheinformationonyour Joint CommissionConnect extranetsitecanhelpyoufocusonorganization-specificproblem areas.Anunderstandingofthecomplexissuesaddressedbythesestandardswillhelpyou assessjusthowreadyforaccreditationyourorganizationisandwillallowyouto continuallyassessyourorganization’sreadinessgoingforward.
II.Aboutthe ComprehensiveAccreditation ManualforBehavioralHealthCareand HumanServices The CAMBHC containsJointCommissionstandards(alsoknownas requirements), elementsofperformance(EPs),NationalPatientSafetyGoals®(NPSGs),andother requirementsapplicabletothecare,treatment,orservicesabehavioralhealthcareor humanservicesorganizationprovides(see the“IdentifyingApplicableStandards”section inthischapter).The CAMBHC includesalltheinformationabehavioralhealthcare organizationorhumanservicesagencyneedstoachieveandmaintaincontinuous compliancewiththeJointCommission’saccreditationandoptionalspecialtycertificationstandards.Themanualalsowillhelporganizationsengageincontinuous performanceimprovementandwillguidestaffindevelopingprocessestoprovidethe highestqualityofsafecare,treatment,orservices.
Uponinitialapplicationforaccreditationandreceiptofadeposittowardaccreditation fees,anorganizationreceivesaccesstoE-dition(whichcontainsaccreditationand certificationstandards)andtothe JointCommissionConnect extranet(whichcontains variousaccreditationtoolsandresourcestohelpprepareforandmaintainaccreditation). Thissecureextranetsitealsoservesastheprimaryavenueforcommunicationbetween anorganizationandTheJointCommission.
The TheJointJointCommissionCommissionmaymayrevisereviseaccreditationaccreditationororcertificationcertificationstandardsstandardsperiodically periodically throughout throughoutthetheyearyearandandpublishpublishthosethosechangeschangesonline,online,ininthetheaccreditationaccreditationmanual,manual,and and in in Joint JointCommissionCommissionPerspectives Perspectives® ®.. ThisofficialJointCommissionnewsletterpublishes revisedorupdatedstandards,EPs,scoring,standardsclarificationsandinterpretations, andotherusefulinformationastheyearprogresses. Because Becauseyouryourorganizationorganizationis is responsible responsibleforformeetingmeetingallallapplicableapplicablestandardsstandardspublishedpublishedin in Perspectives,itisstrongly recommendedthatstaffareensuredaccesstoyourmonthlycopyof Perspectives toaidin yourcomplianceefforts(see “KeepCurrentwithStandardsChangesvia Perspectives” section). Perspectives isavailableonyour JointCommissionConnect extranetsiteunder the“Resources”tabandalsomaybepurchasedatwww.jcrinc.com/the-jointcommission-perspectives/.
TheJointCommissionwebsiteofferse-Alertsfornewcontentorupdates.Signupforor updatee-Alertssubscriptionsathttps://www.jointcommission.org/e-alerts/.
Changestothestandards,whichoccurforavarietyofreasons,aredevelopedwithinput fromaccreditedorganizations,healthcareprofessionals,providers,internalandexternal subjectmatterexperts,consumers,governmentagencies,and/oremployergroupsand areinformedbythescientificliterature.Newstandardsareaddedonlyiftheyrelateto thequalityofcare,treatment,orservicesand/orthesafetyofindividualsserved,havea positiveimpactonhealthoutcomes,canbeaccuratelyandreadilymeasured,andrelate toimportantissuesthatclearlysupporthigh-qualitycare,treatment,orservices. Standardsmayalsoberevisedinresponsetolawandregulationchanges.
AlthoughTheJointCommissionmayannouncerevisionstoaccreditationstandards throughouttheyear,thosechangesaremadetotheE-ditiongenerallyonlytwiceayear: inthespring(withchangesapplicableJuly1)andinthefall(withchangesapplicable January1ofthefollowingyear).Accreditedorganizationsreceiveonecomplimentary subscriptiontotheE-ditionaslongastheymaintainaccreditation.Theprintversionof the CAMBHC manualispublishedonceayearinthefallandaprintupdateserviceis availabletokeepyourmanualcurrentthroughtheyear.Theprintmanualorupdatesare onlyavailableforpurchaseathttps://www.jcrinc.com/store/publications/manuals/.The “What’sNew”table,providedwitheachprintmanualandaccessiblefromtheblue navigationbaracrossthetopoftheE-dition,offersasummaryofthechangesmade sincethe CAMBHC waslastpublishedorposted.
HowIsThisManualOrganized? Thismanualisorganizedintothefollowingtwosectionsforyourconvenience:
Section1:AccreditationRequirements(markedwithgoldtabsintheprintversion andunderthe“AccreditationRequirements”drop-downlistintheE-dition).These chaptersincludestandardsthatarescored,andtheyappearinalphabeticalorder.
Section2:AccreditationProcessInformation(markedwithbluetabsintheprint versionandunderthe“AccreditationProcessInfo”drop-downlistintheE-dition). Thissectionincludesinformationabouttheaccreditationprocess,policies, procedures,andotherrelatedinformation.
Followingismoredetailabouteachsection. See Table2foralistofacronymsusedin thismanual.
Table2.AcronymsUsedinThisManual Acronym Meaning
ACC “TheAccreditationProcess”chapter
AFS AccreditationwithFollow-upSurvey
APR “AccreditationParticipationRequirements”chapter
BHH BehavioralHealthHomeCertification(alsoachapterinthismanual)
CAMBHC ComprehensiveAccreditationManualforBehavioralHealthCare andHumanServices
CSAT CenterforSubstanceAbuseTreatment
CTS “Care,Treatment,andServices”chapter
CW “ChildWelfare”chapter
E-App electronicapplicationforaccreditation
EC “EnvironmentofCare”chapter
EM “EmergencyManagement”chapter
EP elementofperformance
ESC EvidenceofStandardsCompliance
ESP EarlySurveyPolicy(optionfororganizationsnotpreviously accredited)
FSA FocusedStandardsAssessment
HAI healthcare–associatedinfection
HIPAA HealthInsurancePortabilityandAccountabilityActof1996
HRM “HumanResourcesManagement”chapter
IC “InfectionPreventionandControl”chapter
ICM IntracycleMonitoring
ILSM interimlifesafetymeasures
IM “InformationManagement”chapter
Table2. (continued) INTRO
“Introduction:HowJointCommissionAccreditationCanHelponthe RoadtoHighReliability”chapter
LD “Leadership”chapter
LS “LifeSafety”chapter
LTA Limited,TemporaryAccreditation
MM “MedicationManagement”chapter
NPSG NationalPatientSafetyGoals® (alsoachapterinthismanual)
OQPS OfficeofQualityandPatientSafety
OSHA OccupationalSafetyandHealthAdministration
OTP opioidtreatmentprogram(alsoachapterinthismanual)
PDA PreliminaryDenialofAccreditation
PFI PlanforImprovement
PI “PerformanceImprovement”chapter
POA PlanofAction
POC PlanofCorrection
QR “TheJointCommissionQualityReport”chapter
RC “RecordofCare,Treatment,andServices”chapter
RCA rootcauseanalysis
RFI RequirementforImprovement
RI “RightsandResponsibilitiesoftheIndividual”chapter
RWD “RequiredWrittenDocumentation”chapter
SAFER™ SurveyAnalysisforEvaluatingRisk®
SAMHSA SubstanceAbuseandMentalHealthServicesAdministration
SAP “StandardsApplicabilityProcess”chapter
SE “SentinelEventPolicy”chapter
Table2. (continued)
SIG StandardsInterpretationGroup
SSIS “SafetySystemsforIndividualsServed”chapter
SOC™ StatementofConditions™
WT “WaivedTesting”chapter
AccreditationRequirements ThefirstsectionofthismanualcontainstheaccreditationstandardsfortheBehavioral HealthCareandHumanServicesAccreditationProgram,whichconsistsofJoint Commissionstandards,EPs,andotherrequirementsapplicabletoallorganizations accreditedintheprogram.
Thismanualcontainsthefollowingstandardschapters:
“ “Accreditation AccreditationParticipationParticipationRequirementsRequirements””(APR): (APR): Consistsofspecificrequirementsfor participationintheaccreditationprocessandformaintaininganaccreditationaward.
“ “Care,Care,Treatment,Treatment,andandServicesServices””(CTS): (CTS): Covershowcare,treatment,andservicesare providedthroughthesuccessfulcoordinationandcompletionofaseriesofcore processes.
“ “Environment EnvironmentofofCareCare®®””(EC): (EC): Describeshowtomaintainasafe,functional,and effectiveenvironmentforindividualsserved,staff,andothervisitorsintheorganization.
“ “Emergency EmergencyManagementManagement””(EM): (EM): Ensuresthattheorganizationhasadisasterplanin place.
“ “HumanHumanResourcesResourcesManagementManagement””(HRM): (HRM): Outlinesprocessesforstaffmanagement.
“ “InfectionInfectionPreventionPreventionandandControlControl””(IC): (IC): Helpsorganizationsidentifyandreducethe riskofacquiringandtransmittinginfections.
“ “Information InformationManagementManagement””(IM): (IM): Directsorganizationstoobtain,manage,anduse informationtoprovide,coordinate,andintegratecare,treatment,andservices.
“ “Leadership Leadership””(LD): (LD): Reviewsstructureandrelationshipsofleadershipandthemaintenanceofacultureofsafety,quality,andoperationalperformance.
“ “LifeLifeSafetySafety””(LS): (LS): Coversfireprotectionsystems,firedetectionsystems,andkeyfire safetybuildingfeaturesthatarechallengingforbehavioralhealthcareandhuman servicesorganizations.
“ “Medication MedicationManagementManagement””(MM): (MM): Addressesthestagesofmedicationuse,including selection,storage,andsafemanagementofmedications,ordering,preparingand dispensing,administration,monitoringofeffect,andevaluationoftheprocesses.
“ “NationalNationalPatientPatientSafetySafetyGoalsGoals””(NPSG): (NPSG): Includesspecificactionsthatorganizationsare expectedtotaketopreventmedicalerrors,suchasthosecausedbymedicationerrors, harmassociatedwithhealthcare–associatedinfections,andsafetyconcernsacrossvaried behavioralhealthcareandhumanservicespopulations.
“ “Performance PerformanceImprovementImprovement””(PI): (PI): Focusesonusingdatatomonitorperformance, compilingandanalyzingdatatoidentifyimprovementopportunities,andtakingaction onimprovementpriorities.
“ “RecordRecordofofCare,Care,Treatment,Treatment,andandServicesServices””(RC): (RC): Coverstheplanningfunction (componentsofclinicalrecords,authentication,timeliness,andrecordretention)aswell asdocumentationofitemsintheclinical/caserecordforanindividualserved.
“ “RightsRightsandandResponsibilitiesResponsibilitiesofofthetheIndividualIndividual””(RI): (RI): Addressesinformedconsent, participatingindecisionmaking,andrespectingtherightsoftheindividualserved.
“ “WaivedWaivedTestingTesting””(WT): (WT): Coverspolicies,identifyingstaffresponsibleforperforming andsupervisingwaivedtesting,competencyrequirements,qualitycontrol,andrecord keeping.
Thismanualalsocontainsanoptionalcertificationstandardschapter, “ “Behavioral Behavioral Health HealthHomeHome””(BHH), (BHH), asdescribedfurtherinthe“AccreditationProcessInformation” section.
AccreditationProcessInformation Inadditiontothestandardschapters,themanualandE-ditionincludeinformation abouttheaccreditationprocess,policies,procedures,andotherrelatedinformation.The “AccreditationProcessInformation”partofthemanualcomprisesthefollowing chapters:
