Accreditation Program: Behavioral Health Care

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Accreditation Program: Behavioral Health are National Patient Safety Goals A indicates scoring category A; indicates scoring category ; indicates situational decision rules apply; indicates 2010 The Joint ommission

Accreditation Program: Behavioral Health are hapter: National Patient Safety Goals Goal 1 Improve the accuracy of the identification of individuals served. NPSG.0001 Use at least two identifiers when providing care, treatment, or services. Note: Treatments covered by this goal include high-risk interventions and certain high risk medications (for example, methadone). In some settings, use of visual recognition as an identifier is acceptable. Such settings include those that regularly serve an individual (for example, therapy) or serve only a few individuals (for example, a group home). These are settings in which the individual stays for an extended period of time, staff and populations served are stable, and individuals receiving care are well-known to staff. Rationale for NPSG.0001 Errors involved in misidentification of the individual served can occur in virtually all stages of diagnosis and treatment. The intent for this goal is twofold: first, to reliably identify the individual as the person for whom the service or treatment is intended; second, to match the service or treatment to that individual. Acceptable identifiers may be the individual s name, an assigned identification number, telephone number, or other person-specific identifier. 2. Elements of Performance for NPSG.0001 Use at least two identifiers of the individual served when administering medications or collecting specimens for clinical testing. The room number or physical location of the individual served is not used as an identifier. (See also MM.05.009, EPs 8 and 11) Label containers used for specimens in the presence of the individual served. A A indicates scoring category A; indicates scoring category ; indicates situational decision rules apply; indicates Page 2 of 12 2010 The Joint ommission

Accreditation Program: Behavioral Health are hapter: National Patient Safety Goals Goal 7 Reduce the risk of health care associated infections. NPSG.07.001 omply with either the current enters for Disease ontrol and Prevention (D) hand hygiene guidelines or the current World Health Organization (WHO) hand hygiene guidelines. Note: This element of performance applies only to organizations that provide physical care. Rationale for NPSG.07.001 According to the enters for Disease ontrol and Prevention, each year, millions of people acquire an infection while receiving care, treatment, or services in a health care organization. onsequently, health care-associated infections (HAIs) are a safety issue affecting all types of health care organizations. One of the most important ways to address HAIs is by improving the hand hygiene of health care staff. ompliance with the World Health Organization (WHO) or enters for Disease ontrol and Prevention (D) hand hygiene guidelines will reduce the transmission of infectious agents by staff to individuals served, thereby decreasing the incidence of HAIs. To ensure compliance with this National Patient Safety Goal, an organization should assess its compliance with the D and/or WHO guidelines through a comprehensive program that provides a hand hygiene policy, fosters a culture of hand hygiene, and monitors compliance and provides feedback. Following safe hand hygiene practices is important in all organizations; however, the risk to individuals served increases when there is physical contact. In these situations, it is more important to follow formal hand hygiene guidelines. This requirement, therefore, applies only to organizations that provide physical care. 2. 3. Elements of Performance for NPSG.07.001 Implement a program that follows categories IA, IB, and I of either the current enters for Disease ontrol and Prevention (D) or the current World Health Organization (WHO) hand hygiene guidelines. (See also I.004.01, EP 5) Note: This element of performance applies only to organizations that provide physical care. Set goals for improving compliance with hand hygiene guidelines. (See also I.03.001, EP 3) Note: This element of performance applies only to organizations that provide physical care. Improve compliance with hand hygiene guidelines based on established goals. Note: This element of performance applies only to organizations that provide physical care. A A A A indicates scoring category A; indicates scoring category ; indicates situational decision rules apply; indicates Page 3 of 12 2010 The Joint ommission

Accreditation Program: Behavioral Health are hapter: National Patient Safety Goals Goal 8 Accurately and completely reconcile medications across the continuum of care. NPSG.08.001 A process exists for comparing the current medications of the individual served with those ordered for the individual while under the care of the organization. Note: This standard is not in effect at this time. Rationale for NPSG.08.001 Individuals served are at high risk for harm from adverse drug events when communication about medications is not clear. The chance for communication errors increases whenever persons involved in an individual's care change. ommunicating about the medication list, making sure it is accurate, and reconciling any discrepancies whenever new medications are ordered or current medications are adjusted are essential to reducing the risk of transition-related adverse drug events. 2. 3. 4. Elements of Performance for NPSG.08.001 At the time the individual served enters the organization or is admitted, a complete list of the medications he or she is taking at home (including dose, route, and frequency) is created and documented. The individual and, as needed, the family are involved in creating this list. The medications ordered for the individual served while under the care of the organization are compared to those on the list created at the time of entry to the organization or admission. Any discrepancies (that is, omissions, duplications, adjustments, deletions, additions) are reconciled and documented while the individual is under the care of the organization. When the individual's care is transferred within the organization, the current provider(s) informs the receiving provider(s) about the up-to-date reconciled medication list and documents the communication. Note 1: Updating the status of a individual s medications is also an important component of all care hand-offs. Note 2: This element of performance is not in effect at this time. A indicates scoring category A; indicates scoring category ; indicates situational decision rules apply; indicates Page 4 of 12 2010 The Joint ommission

Accreditation Program: Behavioral Health are hapter: National Patient Safety Goals NPSG.08.02.01 When an individual served is referred to or transferred from one organization to another, the complete and reconciled list of medications is communicated to the next provider of service, and the communication is documented. Alternatively, when an individual served leaves the organization s care to go directly to his or her home, the complete and reconciled list of medications is provided to the individuals s known primary care provider, the original referring provider, or a known next provider of service. Note 1: When the next provider of service is unknown or when no known formal relationship is planned with a next provider, giving the individual served and, as needed, the family the list of reconciled medications is sufficient. Note 2: This standard is not in effect at this time. Rationale for NPSG.08.02.01 The accurate communication of a reconciled medication list to the next provider of service reduces the risk of transition-related adverse drug events. The communication enables the next provider of service to receive thorough knowledge of the individual's medications and to safely order or prescribe other medications that may be needed. This communication is especially important at transitions in care when an individual is referred to another organization or transferred from one organization to another. 2. Elements of Performance for NPSG.08.02.01 The individual s most current reconciled medication list is communicated to the next provider of service, either within or outside the organization. The communication between providers is documented. At the time of transfer, the transferring organization informs the next provider of service how to obtain clarification on the list of reconciled medications. A indicates scoring category A; indicates scoring category ; indicates situational decision rules apply; indicates Page 5 of 12 2010 The Joint ommission

Accreditation Program: Behavioral Health are hapter: National Patient Safety Goals NPSG.08.03.01 When an individual served leaves the organization s care, a complete and reconciled list of the individual s medications is provided directly to the individual and, as needed, the family, and the list is explained to the individual and/or family. Note: This standard is not in effect at this time. Rationale for NPSG.08.03.01 The accurate communication of the medication list to the individual and, as needed, the family, reduces the risk of transition-related adverse drug events. A thorough knowledge of the individual s medications is essential for the individual s primary care provider or next provider of service to manage the subsequent stages of care for the individual. Elements of Performance for NPSG.08.03.01 When the individual leaves the organization s care, the current list of reconciled medications is provided and explained to the individual and, as needed, his or her family. This interaction is documented. Note 1: Individuals and families are reminded to discard old lists and to update any records with all medication providers or retail pharmacies. Note 2: This element of performance is not in effect at this time. A indicates scoring category A; indicates scoring category ; indicates situational decision rules apply; indicates Page 6 of 12 2010 The Joint ommission

Accreditation Program: Behavioral Health are hapter: National Patient Safety Goals NPSG.08.04.01 In settings where medications are used minimally, or prescribed for a short duration, modified medication reconciliation processes are performed. Note 1: This requirement does not apply to organizations that do not administer medications. It may be important for health care organizations to know which types of medications their patients are taking because these medications could affect the care, treatment, or services provided. Note 2: This standard is not in effect at this time. Rationale for NPSG.08.04.01 A number of settings exist in which medications are not used, are used minimally, or are prescribed for only a short duration. This includes areas such as the emergency department, urgent and emergent care, convenient care, office-based surgery, outpatient radiology, ambulatory care, and behavioral health care. In these settings, obtaining a list of the original, known, and current medications that the individual served is taking at home is still important; however, obtaining information on the dose, route, and frequency of use is not required. 2. 3. 4. 5. Elements of Performance for NPSG.08.04.01 The organization obtains and documents an accurate list of the individual s current medications and known allergies in order to safely prescribe any setting-specific medications (for example, intravenous contrast media, local anesthesia, antibiotics) and to assess for potential allergic or adverse drug reactions. When only short-term medications (for example, a preprocedure medication or a short-term course of an antibiotic) will be prescribed and no changes are made to the individual's current medication list, the individual and, as needed, his or her family are provided with a list containing the short-term medication additions that the individual will continue after leaving the organization. Note 1: This list of new short-term medications is not considered to be part of the original, known, and current medication list. When individuals leave these settings, a list of the original, known, and current medications does not need to be provided, unless the individual is assessed to be confused or unable to comprehend adequately. In this case, the family is provided both medication lists and the circumstances are documented. Note 2: This element of performance is not in effect at this time. In these settings, a complete, documented medication reconciliation process is used when: Any new long-term (chronic) medications are prescribed. In these settings, a complete, documented medication reconciliation process is used when: There is a prescription change for any of the individual s current, known long-term medications. In these settings, a complete, documented medication reconciliation process is used when: The individual is subsequently admitted to an organization from these settings for ongoing care. A indicates scoring category A; indicates scoring category ; indicates situational decision rules apply; indicates Page 7 of 12 2010 The Joint ommission

Accreditation Program: Behavioral Health are hapter: National Patient Safety Goals 6. When a complete, documented, medication reconciliation is required in any of these settings, the complete list of reconciled medications is provided to the individual, and his or her family as needed, and to the individual s known primary care provider or original referring provider or a known next provider of service. A indicates scoring category A; indicates scoring category ; indicates situational decision rules apply; indicates Page 8 of 12 2010 The Joint ommission

Accreditation Program: Behavioral Health are hapter: National Patient Safety Goals Goal 15 The organization identifies safety risks inherent in the population of the individuals it serves. NPSG.15.001 Identify individuals at risk for suicide. Rationale for NPSG.15.001 Suicide of an individual served while in a staffed, round-the-clock care setting is a frequently reported type of sentinel event. Identification of individuals at risk for suicide while under the care of or following discharge from a health care organization is an important step in protecting these at-risk individuals. 2. 3. Elements of Performance for NPSG.15.001 onduct a risk assessment that identifies specific characteristics of the individual served and environmental features that may increase or decrease the risk for suicide. Address the immediate safety needs and most appropriate setting for treatment of the individual served. When an individual at risk for suicide leaves the care of the organization, provide suicide prevention information (such as a crisis hotline) to the individual and his or her family. A indicates scoring category A; indicates scoring category ; indicates situational decision rules apply; indicates Page 9 of 12 2010 The Joint ommission

Accreditation Program: Behavioral Health are hapter: National Patient Safety Goals Foster are and Shelter Services Applicability Grid Standard/ Requirement Number EP Number Adult National Patient Safety Goals (NPSG) NPSG.0001 1 2 NPSG.07.001 1 NPSG.08.001 1 Therapeutic child & youth Foster are Traditional child & youth Respite are Shelter 2 X X X X X 3 X X X X X 2 3 4 NPSG.08.02.01 1 2 NPSG.08.03.01 1 NPSG.08.04.01 1 2 3 4 5 6 NPSG.15.001 1 X X X X 2 X X X X 3 X X X X A indicates scoring category A; indicates scoring category ; indicates situational decision rules apply; indicates Page 10 of 12 2010 The Joint ommission

Transitional/ supportive living Technology-based Residential 24-hour therapeutic school Group home Therapeutic day school Partial hospitilization Intensive outpatient Day treatment Adult day care Outpatient Outdoor Inpatient crisis stabilization In-home Forensic orrectional Accreditation Program: Behavioral Health are hapter: National Patient Safety Goals Behavioral Health are Settings Applicability Grid Behavioral Health Settings Standard/ Requirement Number EP Number National Patient Safety Goals (NPSG) NPSG.0001 1 X X X X X X X X X X X X X X X 2 X X X X X X X X X X X X X X X NPSG.07.001 1 X X X X X X X X X X X X X X 2 X X X X X X X X X X X X X X X 3 X X X X X X X X X X X X X X X NPSG.08.001 1 X X X X X X X X X X X X X X X 2 X X X X X X X X X X X X X X X 3 X X X X X X X X X X X X X X X 4 X X X X X X X X X X X X X X X NPSG.08.02.01 1 X X X X X X X X X X X X X X X 2 X X X X X X X X X X X X X X X NPSG.08.03.01 1 X X X X X X X X X X X X X X X NPSG.08.04.01 1 X X X X X X X X X X X X X X X 2 X X X X X X X X X X X X X X X 3 X X X X X X X X X X X X X X X 4 X X X X X X X X X X X X X X X 5 X X X X X X X X X X X X X X X 6 X X X X X X X X X X X X X X X NPSG.15.001 1 X X X X X X X X X X X X X X X X 2 X X X X X X X X X X X X X X X X 3 X X X X X X X X X X X X X X X X A indicates scoring category A; indicates scoring category ; indicates situational decision rules apply; indicates Page 11 of 12 2010 The Joint ommission

Eating Disorders Vocational Rehabilitation Services Peer support services Employment services Family suuport services ommunity integration services are coordination/case management services hild & youth services Adult services hild/youth Adult Family Preservation Services/ Wraparound Services-children/youth hild/youth Adult Opioid Accreditation Program: Behavioral Health are hapter: National Patient Safety Goals Behavioral Health are Services Applicability Grid Addictions Services Intellectual Disabilities Mental Health Services Recovery or Resilience Services Standard/ Requirement Number EP Number National Patient Safety Goals (NPSG) All applicability for the National Patient Safety Goal (NPSG) hapter is reflected in the "Foster are and Shelter Services Applicability Grid" and the "Behavioral Health are Settings Applicabilty Grid". A indicates scoring category A; indicates scoring category ; indicates situational decision rules apply; indicates Page 12 of 12 2010 The Joint ommission

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