Overview of the…
State & Psychiatric Hospital Compliance Collaborative (SPHCC)
The Mission
The State & Psychiatric Hospital Compliance Collaborative (SPHCC) is an online repository of compliance information and a communication forum for participating psychiatric hospitals. It was created to facilitates the agreement of member/subscribers to seek and share information in the interest of advancing standards compliance, survey success, and the improvement of patient care quality and safety.
About Us
SPHCC is a service of the consulting firm: Fields & Associates, Inc. (F&A) that was founded in 1997. The collaborative began operation in 2007 and is directed by Richard Fields, MD, a senior, nationally recognized, multi-board certified psychiatrist who was previously a state hospital CEO, CMS surveyor, Joint Commission surveyor and consultant for Joint Commission Resources and Joint Commission International. He has been consulting with psychiatric hospitals for over 25 years. SPHCC is also supported by a special pool of Associates who have successfully assisted hospitals in more than 28 states to achieve, maintain and improve standards compliance and survey readiness. Much of that success is due to the fact that our pool contains one of the largest cadres of behavioral health professionals with formal training as CMS and/or TJC surveyors.
The Need
• So many changes – In 2003, The Joint Commission (TJC) restructured its survey process and standards in an initiative called Shared Visions/New Pathways. Since that time, there has been an endless barrage of updates, revisions and modifications as well as new standards, new goals, new points of emphasis and new survey technologies. More recently the Centers for Medicare and Medicaid Services (CMS) has also begun issuing final rulings in such key areas as restraint and seclusion. Now, to keep its deeming authority, TJC also has to update requirements to match CMS. It is hard to keep up.
• So little relevant information – TJC and others have many publications, listservs, meetings and conferences on accreditation. However most of that focuses on general, medical/surgical hospitals with only a portion of the information they provide being relevant and useful for psychiatric hospitals. CMS has far less such material and what it does have (e.g., clarifications, final rulings) is often very difficult to locate. It is hard to find information specifically relevant to psychiatric hospitals.
• So hard to get/stay ready for survey – While most organizations make some effort to routinely report/collect compliance related data, the difficulty in maintaining sufficient motivation and/or dedicated manpower for compliance monitoring, evaluation and planning make it hard to do more than ramp up for survey in the last 6 months.
• So few sources of good, timely advice – The Joint Commission provides Standards Interpretation support, publishes clarifications/FAQs and can make consultation available through Joint Commission Resources. However the former often lacks the experience/perspective of mental health and the latter is relatively expensive with time-limited availability. CMS publishes updated rulings with clarifications (that are difficult to find) but has no consultation service. The foregoing combined with the relatively small number of mental health professionals with formal CMS/TJC training and surveyor experience make it hard to obtain affordable, relevant and reliable expert advice.
Meeting the Need
SPHCC responds to the above needs with an array of online and on site supports to include:
• Monthly Compliance Information Summaries – 4 official TJC publications, CMS quarterly provider updates and relevant websites are continually monitored by a cadre of former TJC and CMS surveyors. The relevant (only) findings are presented online in a monthly Reading Tips Newsletter with quick reviews, links to additional details and identification of relevance to key staff. The new blog format of the newsletter also allows readers to interact with other facilities around specific article topics as well as ask questions that are answered by our consultant team. To see a sample newsletter go to: SPHsample.net. This support is the easiest way to keep up with ever changing requirements of CMS and TJC.
• Custom Resource Pages (CRP) – Each member organization is provided with a customized, online homepage with links to the topics of greatest interest select by them. These are updated quarterly and augmented by our assisted compliance issue research service. Simply make a request and our team will collect the relevant information and post it to your website. The CRP also serves as an archive for the member’s past reports of surveys and F&A consultation reports. This support saves hours of staff searching to find, relevant compliance information and places it on your electronic doorstep.
• Multi-Year Compliance Plan with Mock Survey Plus – SPHCC has developed a 3-year ongoing compliance approach based on a small number (4-5) of strategically timed and externally assisted (by F&A Associates and/or sister facility staff) refresher-checkups. The plan utilizes a customized balance of on and off-site efforts that culminate in a CMS and/orTJC simulated survey with enhanced debriefing/education for key staff. This plan provides the structure for cost-effective, time-efficient well-structured year-round survey readiness.
• Unique Mental Health Consultant Cadre – SPHCC is supported by the F&A Associate pool. This pool contains one of the largest groups in the country of mental health professionals with the rare insight that comes from actual experience as CMS and/or TJC surveyors and considerable work/consulting experience in/with state and psychiatric hospitals and units across the country. Members can obtain their supportive expertise/advice onsite and via e-mail, fax, telephone, teleconference, podcast, newsletter blog/posts. This is also available via hotline 24/7 during an organization’s official CMS or TJC survey.
Who will benefit
Although anyone in need of TJC or CMS compliance information, clarification or examples will find it useful to participate in SPHCC, the following staff should find it especially beneficial:
• Survey Coordinators and PI Department Directors/staff
• Chairs and members of Focused Standards Assessment (FSA) review committees
• Administrative and clinical Leaders/Discipline chiefs
• Chairs and members of key standing committees (e.g., MEC, P&T, Safety Committee, IC Committee, Credentialing & Privileging Committee, etc).
• Those expecting to participate in major survey activities (e.g., interviews with leadership, engineering, medical staff, nursing, human resources and system tracers for medication management, data use and infection control)
Membership Fees, Subscription Fees and Discounts
• Standard annual membership + newsletter fee is $800.00 per hospital.
• Premier annual membership + newsletter fee is $1,250.00 per hospital.
• Newsletter annual subscription (without membership) fee is 400.00 per hospital
• 20% discount when 2-7 hospitals in a state, system or NASMHPD region join together
• 40% discount when 8 or more hospitals in a state, system or NASMHPD region join together
• 20% and 40% discounts are available with 2 and 3-year memberships respectively
• 50% recession discount available for State Psychiatric Hospitals until the end of the recession
• 60% ‘Survey Sharing’ membership discount or FREE Newsletter subscription for hospitals willing to share recent or upcoming surveys.
• Note: System membership (e.g., state central office or corporate/governing body) and newsletter subscriptions can be negotiated
• For more details go to: www.SPHjoin.net
To Contact Us (To request a website tour or more information)
• Customer Service Online: www.SPHsupport.net
• Customer Service Tel: 770.389.3800
• Customer Service Fax: 770.389.3700
Click here to download a PDF version of this overview
Thank You