Barrins & Associates’ Continuous Survey Readiness Program for Behavioral Healthcare organizations incorporates a proven strategy for ongoing compliance with JCAHO standards and continuous readiness for your next unannounced JCAHO Survey. The focus of the Continuous Survey Readiness program is on developing the internal capacity of your Behavioral Healthcare organization to operationalize the JCAHO standards and maintain compliance for a state of Continuous Survey Readiness.
Our Continuous Survey Readiness Program begins with a baseline Organizational Assessment and also includes the following:
Periodic Performance Review (PPR) Technical Assistance
Hands-on technical assistance with completion of the annual PPR required by JCAHO ensures that you have an accurate evaluation of your level of standards compliance and survey readiness. A thorough and accurate PPR is mandatory for maintaining JCAHO accreditation. In order to ensure that your organization completes a thorough and valid PPR, our consultants evaluate policies/procedures, conduct tracers, and assist with the scoring, completion and submission of the PPR.
Focused Medical Record Review Process
Developing a Focused Medical Record Review Process is critical to a successful JCAHO Continuous Survey Readiness program. Our consultants work with your Behavioral Healthcare team to design a Focused Medical Record Review process that monitors compliance with all of the key JCAHO documentation standards. We also provide “best practice” examples of JCAHO compliant medical records documentation.
Internal Tracer Process
Developing an Internal Tracer Process is another key element of a successful JCAHO Continuous Survey Readiness program. Our consultants provide training on how to conduct tracers and incorporate the results of these tracers into your Behavioral Healthcare organization’s Performance Improvement program. We provide a user friendly tracer tool that addresses all of the key JCAHO standards and National Patient Safety Goals.
JCAHO Standards Training
Training on the latest JCAHO standards and National Patient Safety Goals ensures that managers and staff understand the intent, rationale, and specific requirements of the standards. Our consultants provide customized training to ensure that your managers and staff understand how the various JCAHO standards are applied in your specific types of Behavioral Healthcare programs. We provide “best practice” examples for meeting the most challenging JCAHO standards.
Mock JCAHO Survey
Mock JCAHO Surveys provide a critical opportunity for your staff to experience the JCAHO Survey process and gain confidence in their survey presentation skills. The Mock Survey simulates the actual schedule of your JCAHO Survey and includes numerous tracers and all of the standard JCAHO Survey interviews. Our consultants are up to date on the most current JCAHO Survey techniques and can coach your managers and staff on how to handle challenging survey issues.
Environment of Care/Life Safety Code Reviews
We provide a Life Safety Code Specialist who is an engineer and expert on both the National Fire Protection Association Life Safety Code and JCAHO Environment of Care standards. We conduct a comprehensive review of your physical plant to determine compliance with the NFPA Life Safety Code. We also provide hands-on technical assistance with completion of the Statement of Condition required by JCAHO. In addition, we evaluate your organization’s compliance with all of the JCAHO Environment of Care standards and develop an action plan for compliance on your JCAHO Survey.
Off-Site Continuous Survey Readiness Support
In addition to on-site visits scheduled throughout the year, we provide Continuous Survey Readiness Support off-site via phone and e-mail consultation. We schedule periodic conference calls to help you stay abreast of new JCAHO standards and changes to Joint Commission requirements. Through our Off-Site Continuous Survey Readiness Support, we troubleshoot for you throughout the year and keep your Behavioral Healthcare organization JCAHO ready.