The Joint Commission announced in its publication Online dated March 1 that surveyors would be placing additional emphasis on assessment of ligature risks in behavioral health areas. Specifically, TJC stated that they would evaluate 3 aspects of this:
- Determine if the organization has previously identified these risks
- Evaluate existing plans for removing the risk
- Evaluate the organizations environmental risk assessment process
Well, we are already seeing more frequent scoring of this process. Problem #1 is a failure to identify the risk. By that we mean a failure to document that you have noticed the potential risk and you have a mitigation strategy that will keep people safe. One of the best tools to use to help identify potential risks is the FGI Design Guide for the Built Environment. This is available as a free download from the FGI website. In the sentence above we used a term, “failure to document you have noticed the potential risk.” This is an all-too frequent occurrence because staff look at something and conclude it is not really a risk because no one has every hurt themselves with that, or no one would ever be able to hurt themselves with that. That’s not good enough. You must document you have recognized it and you have evaluated it and concluded that you can safely manage patients despite that potential risk.
Let’s take a classic example like regular door hinges on the shower room in a geropsych unit. Regular door hinges are a known risk as a ligature point, but staff ignore these hinges because in a geropsych unit the patients are never allowed in the shower room by themselves. They are medically weak and require supervision and assistance during the shower. In this case those hinges never make it to their environmental risk assessment which may make sense to you, but TJC is going to conclude “you never noticed.” Staff conducting the risk assessment need to stop thinking about the “but, but, but” issues that they have already analyzed in their heads. If there is a risk, document it and in your evaluation of the risk, document your “but, but, but” logic.
We suggest for environmental risk assessments of the behavioral health environment to evaluate against 3 criteria; probability that someone will use it, criticality if someone did use it, and detectability if someone attempts to use it (i.e., would we be able to intervene before actual harm occurs). So, in this case the probability that someone will use those door hinges to harm himself or herself is low, because it has never happened and the patient is on one-to-one during the shower. The criticality would be large, but the detectability is larger because the patient is on one-to-one. Therefore, we can safely conclude this is not an issue, not a danger and we can keep patients safe because we have a documented mitigation strategy. So, the key here is don’t fail to document that you know there is a potential hazard and don’t fail to document your mitigation strategy.
TJC in their article in Joint Commission Online threw in one additional criterion which we have avoided in the past because, frankly, it is often part of the problem with any risk assessment, and that is your plan to remove the risk at some far-distant time. For example, “we will remove and replace those hinges in our construction project planned for 2019.” To state a future date while not also documenting a current mitigation strategy will likely lead to an RFI. Saying you will eliminate the hazard in 2 more years is still score-able absent a documented risk assessment, but it appears that TJC is now looking for a future plan to make the environment perfect. You are going to want to establish an annual review process for these risk assessments, so if your 2019 construction slides into 2020, your risk assessment reflects that correct date.