The Joint Commission
On-Site Survey Process
December 7, 2010
Behavioral Health Care Accreditation Team
Mary Cesare-Murphy, Ph.D.
Executive Director
Peggy Lavin, LCSW
Senior Associate Director
Evelyn Choi, MS
Senior Accreditation Specialist
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David Wadner, PhD
Field Director
The Joint Commission is:
 Independent
 Not-for-profit
 Private sector, non-governmental organization
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 Our focus: helping behavioral health
organizations help the people they serve.
Behavioral Health Care Accreditation Program
 Accrediting behavioral health organizations since 1969.
 Currently almost 1900 behavioral health care
organizations are Joint Commission accredited.
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 Accredited organizations range from small, single service
providers to very large, multiple services/programs
organizations.
Who can become accredited under the
Behavioral Health accreditation requirements?
 Community-based Mental Health Services.
 Services for Children and Youth.
 Substance Abuse Treatment Services.
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 Medication Assisted Opioid Treatment Programs.
Programs / Services Accredited
Under Behavioral Health Care Accreditation
 Addictions services
 Medication Assisted Opioid treatment
 Case management agencies
 Outdoor programs
 Corrections
 Outpatient programs
 Crisis stabilization
 Residential/group homes
 Day programs
 Technology-based services
 Family preservation/wraparound
 Therapeutic foster care
 Forensics services
 Transitional/supervised living
 Foster care
 24-hour therapeutic schools
 In-home/community support
 Vocational rehabilitation
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 Eating disorders treatment programs  Therapeutic day schools
Behavioral Health Care Accreditation Standards
for Specific Populations
 Children and Youth
 Individuals with Intellectual/Developmental Disabilities
 Individuals receiving Addiction Treatment or Services
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 Individuals receiving Medication Assisted Treatment for
Opioid Addiction
Behavioral Health Accreditation Program

119 Distinct administrative agencies within 48
states

Examples of states recognizing accreditation:
– Oklahoma
– Ohio
– North Carolina
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State Recognitions
Joint Commission Surveyors
 Experienced behavioral health
care professionals
 Trained, mentored, and monitored
to deliver consistently valuable
surveys
 Each surveyor surveys an average
of15 times per year
 Helping organizations in their
commitment to provide safe and
high quality care, treatment &
services
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 Sharing good practices with you
and your staff
“The Balancing Act”
and
Educator
Consultant
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Evaluator
The On-site Survey Process
 The on-site survey agenda is in sync with
an organization’s normal operational
systems
 On-site survey process is customized to
the setting(s), service(s) and population(s)
served by the organization
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 Focus is on actual delivery of care,
treatment, or services -- not just paperwork
What happens during an on-site survey?
Opening Session: Orientation to the Organization
–
–
–
–
–
What you do
Who you serve
Your staff
Your philosophy and values
How you are organized
 Ensures a survey appropriate to your organization
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 A discussion that provides an opportunity for the
surveyor(s) to learn from you about your organization
Individual “Tracers”
 Traces the continuum of care, treatment or
services provided
 Usually at least 60% of the on-site survey
 Directly involves staff who provide care,
treatment or services
 Individual served is involved if appropriate
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 Follows care, treatment or services provided
throughout the organization
Life Safety Code
 Applies to 24-hour residences
 Life Safety Code Categories:
– Locked facilities
– Lodging or Rooming Houses
– 4 to 16 occupants
– 17 + occupants
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– Hotel and Dormitories
Data Session
Discussion of how the
organization uses data:
– Identification of data to be collected
– Aggregation and analysis
– Use of the data for change
– Annual review of data plan
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– Performance Improvement initiatives
Competence Assessment Session
– Staff selection
– Verification of education
and licensure
– Orientation and training
– Competence assessment
– Performance evaluation
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 Reviews the processes the
organization follows to ensure
that they have sufficient,
competent staff
Systems Tracers Scheduled If Applicable
 Medication Management
– Reviews the medication processes from
prescribing to administrating
 Infection Control
– Reviews processes for preventing and
responding to infections
– Varies based on settings
(e.g. facility-based vs. community-based)
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– Only reviews those aspects relevant to the
organization
 Suicide prevention
– Reviews the organizations suicide prevention
process
 Elopement prevention
– Reviews the organizations elopement procedures
(where applicable)
 Violence prevention
– Reviews the organizations process for preventing
violence within the organization
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Optional Systems Tracers
Daily Briefing
 Start of each day after the first day
 Review of the previous day’s activities
 Opportunity for organization to clarify
misunderstandings
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 Identification of any areas of potential noncompliance with accreditation requirements
Leadership Session
 Discussion with organization leadership
 Last day of survey
 An opportunity for the leaders and surveyor to
discuss how the leaders may be able to use the
surveyors’ observations constructively
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 Based on observations during the survey
Closing Session and Report
– Surveyor(s) provides clear explanation of
survey finding(s)
– Official report is provided on organization's
extranet site within 2-10 days after survey
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 Meeting with CEO, if desired, to review report
 Meeting with staff chosen by organization
 Report
– Organization receives written preliminary
report of any findings
After your Survey
 Generally 45-60 days to resolve any issues found
 Work with your Account Executive
 Seek advice
–
–
Account Executive primary
Standards Interpretation Group
 Don’t forget to make use of the free publicity kit
posted on our web site to publicize your new
status.
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 Final Accreditation Decision posted upon
resolution of findings
Complimentary Support to Guide you
Through your First Accreditation
 Behavioral Health Accreditation Team
 Complimentary conference calls & webinars
 Standards Interpretation Group (630) 792-5900
 Account Executives
 More information at: www.jointcommission.org/BHC
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 Introduction to mentor organizations
Additional Resources Provided by
Joint Commission Resources
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 Educational programs
 Publications
 Consulting services
Behavioral Health Care Accreditation:
How to Apply for Accreditation
1. Request access to The Joint Commission’s
electronic application for accreditation.
3. Complete and submit the application.
4. Make a deposit of $1700 toward your accreditation
fees.
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2. Indicate in the application which month during the
next 12 months you would like your initial on-site
survey to be scheduled.
What do accredited organizations say?
George Condas, PhD, Vice President
Camelot for Kids, Dripping Springs, TX
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“Joint Commission accreditation has assisted
our development into a nationally recognized
organization. Although Camelot has spread
across many states, there is consistency in
how we provide service and execute our
business practices, thanks in part to our
accreditation.”
What do accredited organizations say?
Susan Rushing, PhD, CEO
Burke Center, Lufkin, TX
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“We are under constant pressure to do more
with less. Joint Commission requirements
are the standards we use to assure we don’t
sacrifice quality or safety as we change to
meet new demands. They are the center
around which we organize our systems.”
What do accredited organizations say?
Michael Flora, President and CEO
Ben Gordon Center, DeKalb, IL
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“The Joint Commission Gold Seal tells our staff,
our consumers, our payors, and our contractors
that we mean business, that we mean quality.
That by coming to us, they can expect a standard
of excellence that’s driven by an organization that
is synonymous for quality not only in our country,
but around the world.”
What do accredited organizations say?
Dustin Tibbitts, Executive Director
InnerChange New Haven, Provo, UT
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“I am always impressed by the experience, patience,
and thoroughness of our surveyors. With The Joint
Commission as a partner, I feel like we have a wise
mentor prodding us to do better, to think more clearly,
and to be more efficient.”
Joint Commission
Behavioral Health Care Accreditation
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The Joint Commission’s Gold Seal of ApprovalTM means
your organization has reached for and achieved the highest
level of performance recognition available in the behavioral
health field.
Behavioral Health Care Accreditation Team
Mary Cesare-Murphy, PhD
Executive Director
mcesaremurphy@jointcommission.org
630/792-5790
David Wadner, PhD
Field Director
dwadner@jointcommission.org
Peggy Lavin, LCSW
Senior Associate Director
plavin@jointcommission.org
630/792-5411
Evelyn Choi, MS
Senior Accreditation Specialist
echoi@jointcommission.org
630/792-5866
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630/792-5788