Joint Commission Resources Quality & Safety …

1 Joint Commission Resources Quality & Safety network (JCRQSN) resource GuideBe Prepared: Maximizing Behavioral Healthcare-Related Tracer Activities April 27, 2017 Joint Commission ResourcesBe Prepared: Maximizing Behavioral Healthcare-Related Tracer Activities 2017 Joint Commission Resources 2 of 56 About Joint Commission ResourcesJoint Commission Resources (JCR) is a client-focused, expert resource for healthcare organizations. It partners with these organizations, providing consulting services, educational services, and publications to assist in improving the Quality , Safety , and efficiency of healthcare services, and to assist in meeting the accreditation standards of The Joint Commission . JCR is a subsidiary of The Joint Commission , but provides services independently and confidentially, disclosing no information about its clients to The Joint Commission or others. Visit our web site at: Commission Resources educational programs and publications support, but are separate from, the accreditation activities of The Joint Commission .

2 Attendees at Joint Commission Resources educational programs and purchasers of Joint Commission Resources publications receive no special consideration or treatment in, or confidential information about, the accreditation information in this resource guide has been compiled for educational purposes only and does not constitute any product, service, or process endorsement by The Joint Commission or organizations collaborating with The Joint Commission in the content of these :Interactivation Health Networks is the distributor of the Joint Commission Resources Quality & Safety network series and has no influence on the content of the series. 2017 Joint Commission Resources . The purchaser of this educational package is granted limited rights to photocopy this resource guide for internal educational use only. All other rights for permission to make copies of this publication for any use not covered by these limited rights should be made in writing to: Department of Education Programs, Joint Commission Resources , One Renaissance Boulevard, Oakbrook Terrace, IL Commission ResourcesBe Prepared: Maximizing Behavioral Healthcare-Related Tracer Activities 2017 Joint Commission Resources 3 of 56 TABLE OF CONTENTSP rogram Summary.

3 4 Program Education (CE) Credit ..6 Relevant Standards and Elements of Event Alert 56: Detecting and Treating Suicide Ideation in All Immediately: Surveying, Scoring of: Ligature, Suicide, Self-Harm in Inpatient Psychiatric Door Hanging Hazards in Inpatient Psychiatric American Psychiatric Nurses Association Position Statement: The Use of Seclusion and Analysis for Evaluating Risk (SAFER) Insight into Your Analysis for Evaluating Risk (SAFER) Matrix FAQs ..40 Frequently Asked Questions, Definitions, and Additional Information from the Standards BoosterPak for Use of Restraint and Seclusion for Organizations Using Joint Commission Accreditation for Deemed A: Resources ..50 Appendix B: Faculty Biography ..51 Appendix C: Continuing Education (CE) Accrediting Bodies ..52 Appendix D: Discipline Codes Instructions ..53 Appendix E: Post-Test ..54 Appendix F: JCRQSN Contact Information ..56 Joint Commission ResourcesBe Prepared: Maximizing Behavioral Healthcare-Related Tracer Activities 2017 Joint Commission Resources 4 of 56 Program SummaryThis page provides an overview of the program content and learning objectives.

4 Please refer to the Table of Contents and Program Outline for a detailed list of the topics covered. The information included in this resource guide is intended to support but not duplicate the video presentation content. There may be additional information available online for this topic. Program DescriptionSince 2004, the Tracer Methodology has been an evaluation method where surveyors select a patient, resident, or client and use that person's record as a roadmap to move through an organization to assess and evaluate the organization's compliance with selected standards and the organization's systems of providing care and services. The Tracer Methodology is a significant component of the accreditation process, providing a framework for Joint Commission surveyors to assess standards compliance and patient Safety during on-site surveys. To better address the unique characteristics and relevant issues of each accredited organization, Joint Commission behavioral healthcare surveyors have a wider range of behavioral health-specific tracers to conduct during surveys.

5 For instance, through the use of Tracer Methodology, surveyors evaluate the effectiveness of processes to prevent elopement, therefore enhancing Safety and identifying process, and possibly system-level issues contributing to successful elopements. A surveyor also examines the effectiveness of the organization's suicide prevention strategy and, again, identifies process, and possibly system-level issues contributing to suicide attempts. The surveyor also evaluates the effectiveness of the organization's process to control violence and ensure the Safety of others. Designed for organizations that want a better understanding of tracer implementation and methodologies, this 60-minute live activity provides the information and tools needed to make the most of the opportunities tracers provide related to Behavioral ObjectivesAfter completing this activity, the participant should be able to:1. Identify various tracers that focus on Behavioral Prioritize tracer data to determine the effectiveness of process design in the delivery of safe, high- Quality care in the Behavioral Healthcare Improve processes through use of Tracer Methodology and aggregation of tracer findings AudienceThis activity is essential for those in your organization who are responsible for assessing the Quality and Safety of care provided throughout the organization, as well as those responsible for accreditation compliance, including survey coordinators, risk managers, performance improvement (PI) coordinators, department managers, and others who have a hands-on role in The Joint Commission accreditation process or assessing the systems and processes within the Commission ResourcesBe Prepared.

6 Maximizing Behavioral Healthcare-Related Tracer Activities 2017 Joint Commission Resources 5 of 56 Program OutlineBe Prepared: Maximizing Behavioral Healthcare-Related Tracer Activities April 27, 2017I. Introduction A. Program ContentB. ObjectivesC. FacultyII. Mock Survey National Patient Safety Goal 15A. Assessing and Intervening to Reduce Self-Harm and Suicide Risk in All SettingsB. Surveying Ligature Risk to Reduce the Potential for Self-harm and Suicide Risk In Inpatient Psychiatric SettingsIII. Mock Survey Effective Monitoring, Assessment and Care PlanningA. Effective Staff Assessment and Monitoring for Patients Placed in Restraint and SeclusionB. Effective Care Planning for Patient at Risk for Self-Harm and/or SuicideIV. The Survey Analysis for Evaluating Risk (SAFER) Matrix V. ConclusionVI. Post-Program Live Question and Answer SessionA. Audio only telephone seminar with program faculty for 30 minutes following the Call 1-888-206-0090; enter conference code: e-mail your questions or comments to: Question and Answer SessionDuring the live airing of this program on April 27, 2017, you may be able to talk directly with the faculty when prompted by the program s host.

7 After this date, your message will be forwarded to the appropriate personnel. Immediately following the program, we invite you to join in a live discussion with the program presenters. Call 1-888-206-0090 and enter Conference Code: 7925428 to be included in the submit your question ahead of time or for additional details, please send an e-mail to If you submit your questions after this date, your message will be forwarded to the appropriate can also receive answers to your questions by calling The Joint Commission s Standards Interpretation Hotline at 630-792-5900, option 6. Program Broadcast TimeEastern:Central: Mountain:Pacific: 2:00 to 3:00 :00 to 2:00 :00 to 1:00 :00 to 12:00 Commission ResourcesBe Prepared: Maximizing Behavioral Healthcare-Related Tracer Activities 2017 Joint Commission Resources 6 of 56 Continuing Education (CE) CreditAfter viewing the JCR Quality & Safety network presentation and reading this resource guide , please complete the required online CE/CME credit activities (test and evaluation form).

8 The test measures knowledge gained and/or provides a means of self-assessment on a specific topic. The evaluation form provides us with valuable information regarding your thoughts on the activity s Quality and to the Program Presentation Day1. Login to the JCRQSN Learning Management System web site at Select the course for this program, Be Prepared: Maximizing Behavioral Healthcare-Related Tracer Activities When prompted, choose Access Content to confirm that you would like to access this Display and print the desired documents ( resource guide , etc.).Online Process for CE/CME Credit1. Read the course materials and view the entire video Login to the JCRQSN Learning Management System web site at 3. Select Be Prepared: Maximizing Behavioral Healthcare-Related Tracer Activities from the courses menu : This assumes you have already been enrolled in the program, as described If you did not view the broadcast video presentation, view it online.

9 5. Complete the online post test (see Appendix E). You have up to three attempts to successfully complete the test with a minimum passing score of 80%. Physicians must take the post test to obtain Complete the program evaluation On the top-left corner of the main course page, you will see your completion status in the Status Select Get Certificate from within the Status block to print your completion : Certificates for other completed courses can be printed from the My History tab, as Commission ResourcesBe Prepared: Maximizing Behavioral Healthcare-Related Tracer Activities 2017 Joint Commission Resources 7 of 56 Relevant Standards and Elements of PerformanceProgram: HospitalChapter: Environment of CareStandard: : The hospital establishes and maintains a safe, functional : The environment is constructed, arranged, and maintained to foster patient Safety , provide facilities for diagnosis and treatment, and provide for special services appropriate to the needs of the : (None)EPs1.

10 Interior spaces meet the needs of the patient population and are safe and suitable to the care, treatment, and services Lighting is suitable for care, treatment, and Areas used by patients are clean and free of offensive The hospital keeps furnishings and equipment safe and in good : HospitalChapter: National Patient Safety GoalsStandard: : Identify patients at risk for : This requirement applies only to psychiatric hospitals and patients being treated for emotional or behavioral disorders in general : Suicide of a patient 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 :1. Conduct a risk assessment that identifies specific patient characteristics and environmental features that may increase or decrease the risk for Address the patient's immediate Safety needs and most appropriate setting for When a patient at risk for suicide leaves the care of the hospital, provide suicide prevention information (such as a crisis hotline) to the patient and his or her : HospitalChapter: Provision of Care, Treatment, and ServicesStandard: : The hospital plans the patient's : (None)EPs:1.