Joint Commission

Recently, the Joint Commission instituted a markedly different onsite accreditation survey process called “Shared Visions—New Pathways.”  Unlike the historic review process that emphasized document review and leadership interviews, the new process, initiated in 2004, utilizes a “tracer” methodology with a focus on patient care and staff understanding of this care.  Individual standards and related scoring protocols have been modified to reflect the need for increased measurable outcomes related to direct practice and patient care.  Organizations are likewise required to engage in a structured self-evaluation process termed the “Periodic Performance Reviews.”  An organization can complete this review internally, with results sent electronically to the Joint Commission, or through an onsite process with a Joint Commission surveyor assessing the organization and making recommendations (in writing or verbally, depending upon the option chosen).  These and other less dramatic changes make the new survey process significantly different than it has been in the past.

As with anything new, organizations are struggling to understand the nature and implications of these new processes.  To further its capacity to assist agencies with these changes and related survey issues, Clinical Services Management, P.C. has expanded its consulting staff with the recent addition of Craig Blum, Ph.D.  Dr. Blum brings to CSM a wealth of varied experiences and a strong national perspective on the delivery of healthcare.  During the last 7 years he has been employed as a Joint Commission surveyor reviewing over 300 separate facilities across the behavioral healthcare spectrum (i.e., mental health, substance abuse, developmental disabilities, and others).  Prior to leaving the Joint Commission, Dr. Blum was full trained under both Behavioral and Hospital Manuals and certified in the “Shared Visions – New Pathways” approach.  Dr. Blum also successfully completed a number of surveys utilizing this new protocol.

Dr. Blum, in conjunction with CSM, has developed a new approach to assisting organizations with these changing processes, as well as the traditional demands of the Joint Commission accreditation procedure.  Created as a “Teaching Model,” the system replaces the common practice of “mock surveys,” which historically offered only a modest benefit and now seems even less adequate with the new tracer methodology.  The teaching model utilizes an experiential approach that first helps staff to understand the survey process through the eyes of the surveyor.  Next, it exposes them to the process of the tracer methodology, and finally educates them through an interactive debriefing process designed to allow for the exchange of ideas and information.  This unique approach has proven to substantially reduce anxiety by familiarizing staff to the process, as well as allowing for productive feedback and the opportunity of participating in a comprehensive educational experience.  Additionally, it provides for a broader consultation that goes beyond just preparation for the Joint Commission.

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Clinical Services Management, P.C.
6 Prospect Street, Suite 3B
Midland Park, NJ 07432
Telephone: 201.652.4702
Fax: 201.652.4704


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New Jersey Association of Mental Health and Addiction Agencies

Joint Commission

Substance Abuse & Mental Health Services Administration (SAMHSA)

Centers for Medicare & Medicaid Services (CMS)

Council on Accreditation of Rehabilitation Facilities (CARF)