Joint Commission Issues Update for Suicide Prevention
The elements of performance are intended to support institutions in preventing suicide, with specific requirements for behavioral health care organizations and psychiatric and nonpsychiatric units in general hospitals.
The Joint Commission has announced revisions to its National Patient Safety Goals (NPSGs) addressing suicide prevention to improve the quality and safety of care for patients treated for behavioral health conditions and those identified at high risk for suicide.
The revised requirements (“NPSG 15.01.01—Reduce the Risk for Suicide”) are applicable to all Joint Commission–accredited hospitals and behavioral health care organizations and become effective July 1. The requirements are summarized in the “R-3 [Requirement, Rationale, Reference] Report” on The Joint Commission’s website.
The NPSG encompasses seven elements of performance (EPs) on which The Joint Commission will review hospitals and behavioral health care organizations during accreditation surveys—an increase from three EPs in the existing “NPSG 15.01.01 - Identify individuals at risk for suicide.”
The Joint Commission began its re-evaluation of the NPSGs in 2016 and held five technical expert panel meetings between June 2017 and March 2018. The revisions have been posted on the Prepublication Standards page of The Joint Commission website and will be available until the end of June.
“This revised version and the accompanying resource compendium will more robustly support health care organizations in preventing suicide among patients in their care,” said David W. Baker, M.D., M.P.H., executive vice president of the Division of Health Care Quality Evaluation at The Joint Commission, in a statement.
There are seven elements of performance with specific requirements. The text of the “R-3 Report” includes, for each requirement, specific requirements for behavioral health care organizations, psychiatric units in general hospitals, and nonpsychiatric units in general hospitals. Each requirement is also followed by a rationale and references to published literature supporting the requirement and rationale. The elements of performance include the following requirements and their rationale:
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Environmental risk assessment and action to minimize suicide risk: “The health care environment, including patient rooms, patient bathrooms, corridors, and common patient care areas can contain features that patients can use to attempt suicide. The most common hazards for suicide risk are ligature anchor points that can be used for hanging. However, there are many other types of hazards, so it is important to do a thorough assessment of the environment to minimize all potential suicide risks. For nonpsychiatric units that are not required to be ligature-resistant, the focus should be on rigorous implementation of protocols to keep patients safe, especially one-to-one monitoring.”
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Use of a validated screening tool to assess patients at risk: “Patients being evaluated or treated for behavioral health conditions often have suicidal ideation. Brief screening tools are an effective way to identify individuals at risk for suicide who require further assessment and steps to protect them from attempting suicide. Screening tools should be appropriate for the population to the extent possible (e.g., age-appropriate). When using validated screening tools, organizations should not change the wording of the questions because small changes can affect the accuracy of the tools.”
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Evidence-based process for conducting suicide risk assessments of patients screened positive for suicidal ideation: “Patients with suicidal ideation vary widely in their risk for a suicide attempt depending upon whether they have a plan, intent, past history of attempts, etc. It is important to conduct an in-depth assessment of patients who screen positive for suicide risk in order to determine how to appropriately treat them. The use of an evidence-based assessment process or tool in conjunction with clinical evaluation is effective in determining overall risk for suicide. Examples include the Safe-T Pocket Card and the Columbia-Suicide Severity Rating Scale. The Columbia-Suicide Severity Rating Scale can be used for both screening and more in-depth assessment of patients who screen positive for suicidal ideation using another tool.”
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Documentation of patients’ risk and the plan to mitigate: “It is important for all clinicians who might come in contact with a patient at risk for suicide to be aware of the level of risk and the mitigation plans to reduce that risk. Thus, this information should be explicitly documented in the patient’s record.”
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Written policies and procedures addressing care of at-risk patients and evidence they are followed: “Policies and procedures for monitoring patients at high risk for suicide should include specifics about training and competence assessment of staff. These are essential for ensuring consistent, safe care.”
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Policies and procedures for counseling and follow-up care for at-risk patients at discharge. “Studies have shown that a patient’s risk for suicide is high after discharge from the psychiatric inpatient or emergency department settings. Developing a safety plan with the patient and providing the number of crisis call centers can decrease suicidal behavior after the patient leaves the care of the organization.”
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Monitoring of implementation and effectiveness, with action taken as needed to improve compliance: “High reliability in suicide prevention can only be achieved if there is strict adherence to policies and procedures. Monitoring adherence is therefore essential. In some of the suicides reported to The Joint Commission, the root cause was identified as failure to adhere to policies, such as a period of time when one-to-one monitoring was not done for a high-risk patient.”
In September 2018, a report in The Joint Commission Journal on Quality and Patient Safety found that between 48.5 and 64.9 hospital inpatient suicides occur each year in the United States. That’s “far below the widely cited figure of 1,500 per year,” wrote lead author Scott Williams, Psy.D., director of the Department of Research at The Joint Commission, and colleagues (Psychiatric News, October 12, 2018).
Last year administrators at many hospitals expressed concern about increased monitoring and enforcement of citations by the Centers for Medicare and Medicaid Services (CMS) and The Joint Commission around elimination of ligature risks that were costing facilities exorbitant amounts of money and reducing patient access to appropriate care. At the July 2018 meeting of the APA Board of Trustees, APA CEO and Medical Director Saul Levin, M.D., M.P.A., reported that APA had surveyed 88 facilities in 34 states and the District of Columbia between April and June 2018. Of the 55 that responded, 10 reported having closed inpatient psychiatric units due to the assessment of fines for ligature risks, and 14 reported reducing psychiatric beds. Twenty-three facilities reported paying fines between $100 and $6 million.
APA is continuing to work with the membership, aligned organizations, and facility leadership to advocate for fair and reasonable policies. ■
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Psychiatrics News
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Published online: 28 December 2018
Published in print: December 22, 2018 – January 4, 2019
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