Patient Safety Goal Changes – Suicide

by Expert Advice

Patient Safety Goal Changes – Suicide

by Expert Advice

by Expert Advice

The Joint Commission issued a new statement on national patient safety goal changes for suicide. Here are the details:

Patient Safety Goal Changes – Suicide

NPSG.15.01.01 is consistent with the prior applicability statement but even clearer. The new requirement is applicable only to:

  • Patients in psychiatric hospitals
  • Patients under evaluation or treated for behavioral health conditions as their primary reason for care in general hospitals

The fact is, Sentinel Event Alerts have suggested broadening the focus. And, many EMR’s do provide screening questions for all patients. But, the requirement remains focused on patients who have some behavioral health need as their reason for admission.

EP 1

Although EP 1 changed significantly, it is consistent with what you have been reading in Perspectives this past year. Moreover, it reflects the work of their Suicide Prevention Expert Panel.

They divide the new EP into two sections:

  • Psychiatric hospitals and psychiatric units
  • General care units of hospitals

Psychiatric Hospitals And Units

For psychiatric hospitals and units, it mandates an environmental risk assessment to identify features in the environment that could be used to attempt suicide. More importantly the new EP then states:

“The hospital takes necessary action to minimize the risks, (for example, removal of anchor points, door hinges, and hooks that can be used for hanging.”)

General Care Units

The second part of the EP addresses general care units of hospitals. It requires the hospital to:

“Mitigate the risk of suicide for patients at high risk for suicide, such as 1:1 monitoring, removing objects that pose a risk for self-harm if they can be removed without adversely affecting the patient’s medical care, assessing objects brought into the room by visitors, and using safe transportation procedures when moving patients to other parts of the hospital.”

There is then a note explaining that the “non-psychiatric units are not expected to be ligature resistant environments.” In fact, these facilities should assess clinical areas to identify objects used for self-harm. And then, remove these items from the area around patients identified as high risk for suicide, when possible.

Furthermore, use this information for training for high-risk patients. In this case, developing a checklist to help the staff remember which equipment to remove is useful.

Consistent With Perspectives

EP 1 is consistent with the information published in Perspectives for more than a year now. But, it may appear new for some organizations due for survey in 2019, if you have not focused on this issue since 2016. Past environmental risk assessments for the psychiatric settings would recognize some hazards. Then, hospitals used a mitigation or alternative strategy. They did not need to eliminate the potential hazard.

Instead, in behavioral health settings today, no alternative mitigation strategy is permissible. You must eliminate the potential suicide hazards.

Furthermore, this EP doesn’t differentiate between bedrooms and bathrooms vs. public hallways. Described in the September 2017 Perspectives, it allowed some leeway in public hallways for suspended ceilings. We assume that this flexibility is still permissible. Also, remember this key point point about risk assessments in the behavioral health environment. Stating your plan to renovate and remove the hazards in 2020, or some other future date, is risky. It leaves you vulnerable. for immediate and significant survey findings.

EP 2

EP 2 is equally significant as EP 1. It mandates the use of a “validated screening tool” for the identification of suicide risk.

EP 3

EP 3 then requires the use of an “evidence-based process to conduct a suicide assessment of patients who have screened positive for suicidal ideation.” Furthermore, they require your tool to assess for ideation, plan, intent, suicidal or self-harm behaviors, risk factors, and protective factors.

There is also a note attached to EP 3. It states that you may use a single process or instrument that screens and assesses instead of a two-step process. We believe most psychiatric settings will prefer to use a single instrument.

EP 4

EP 4 then requires that you document the patient’s overall risk for suicide in the mitigation plan. Interestingly while the verb in the EP sentence says “document” there is no “D” icon in the EP. We do see this action as an important and very useful new addition. The fact is, we frequently encounter hospital suicide screens that have no conclusion. And, they don’t quantify specific actions or document the details. Today, many organizations simple state that if the physician wants 1:1, or close observation, he/she will order it. And, if it is not ordered, that means it was not necessary.

Lastly, it appears that suicide assessment occurs because there is a requirement. Unfortunately, the tool isn’t really used to help reach a decision about safety.

EP 5

EP 5 does have a “D” icon! It requires that the staff follow written policies and procedures addressing the care of patients at risk for suicide. They further state that these policies should include:

  • Training and competence assessment of staff who care for patients at risk for suicide. (Note: This requirement appears unique in that they look for a policy and procedure to include the literal content of the training program and competency assessment process.)
  • Guidelines for reassessment
  • Monitoring of patients who are at high risk for suicide.

It is likely that organizations will examine existing policies and procedures. At that time, they will identify gaps in meeting these requirements.

EP 6

EP 6 requires policies and procedures for counseling and follow up care at discharge for patients identified as at risk for suicide. Previously, the only requirement was to provide a phone number for a crisis hotline. Now the expectation appears much more significant. Hospitals should consider the elapsed time between discharge and the first post-discharge appointment. Further, should you make the appointment for the patient or hope they make the appointment on their own?

EP 7

EP 7 is entirely new. You can consider it the performance improvement requirement for the safety goal. This EP requires that you monitor implementation. Specifically, the effectiveness of policies and procedures for screening, assessment, and management of patients at risk for suicide. And then, you need to take  the actions necessary to improve compliance.

You may want to consider the following suggestions for evaluation. The Joint Commission doesn’t mandate these but they are worth considering.

  • The percentage of patients who completed the suicide screen and/or assessment within your required timeframe.
  • The percentage of patients who have a documented conclusion reached on risk of suicide, and staff actions to enhance safety. And the percentage documented with those details after completion of the assessment.
  • Evaluation of inter-rater reliability of staff within disciplines and across disciplines who complete the suicide risk assessment.
  • Compliance rate with staff documentation of behavioral monitoring observations both quantitatively and qualitatively.
  • Verification that the staff performing safety checks according to your policies and procedures have the documented competency to do so.
  • The percentage of patients who have a suicide reassessment documented coinciding with the timeframe established in the organizations policies and procedures.
  • Time to first follow up appointment for inpatients identified as high risk on admission and are subsequently discharged.

Patton Healthcare Consulting

Do you need assistance interpreting and implementing these or other Joint Commission guidelines? Patton Healthcare Consulting provides Joint Commission Compliance Assistance and a full range of pre-survey and post survey services to healthcare organizations. Contact our office at 888-742-4621, via email or through our website contact page to schedule a discussion of your needs and learn more about our compliance and readiness expertise.


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