November 15, 2019 FAQ – Monitoring Requirements for Suicidal Patients

TJC FAQ191115 

  • Issued November 15, 2019

National Patient Safety Goals (NPSG) (Behavioral Health / Behavioral Health Care)


Suicide Risk Reduction – Monitoring High – Risk Patients


What is the  monitoring requirement for patients at high risk for suicide?


  • In units/areas that contain ligature and/or other safety risks, patients determined to be at high-risk for suicide must be under continuous observation with the ability to immediately intervene through the use of 1:1 observation – 1 qualified staff member to 1 high risk patient.  A qualified staff member is one that has been trained and has demonstrated competence in working wit suicidal patients and performing 1:1 observation.
  • In inpatient psychiatric units/designed psychiatric areas that are ligature resistant and free from other  safety risks, it is up to the organization to determine monitoring requirements for patients determined to be at high-risk for suicide and define such in their policy.



July 2019 FAQ – Acceptable Replacements for Solid Ceilings

TJC FAQ 190722

  • Issued July 22, 2019

National Patient Safety Goals (NPSG) (Behavioral Health / Behavioral Health Care)


Ligature and Suicide Risk Reduction – Ceiling Systems

What ceiling systems are allowable as a replacement for a solid ceiling?


A monolithic ceiling must either be a solid structure or use a concealed grid system that meets the following requirements:

  • No exposed components of the ceiling system can be used as a ligature attachment point (i.e. rails, tees, mains)
  • Panels can in no way be removed by the patient.
  • No impact will dislodge the panel(s)




FREE Suicide Prevention Portal on TJC Website


  • Issued May 2019

The Joint Commission is providing FREE ACCESS to Suicide Prevention publications such as relevant issues of their Perspectives newsletter and other publications that contain the recommendations of the Expert Panel on Suicide Prevention, National Patient Safety Goals regarding suicide prevention and tools for evaluating patient level of intent for self-harm.





May 2019 Perspectives: FAQs for Self-Closing and Self-Locking Doors & Video Monitoring

May 2019 Perspectives FAQThe Joint Commission

  • Issued May 2019

The Joint Commission has clarified Expert Panel on Suicide’s Recommendation #1 (November 2017 Perspectives) relating to Self-Closing and Self-Locking Doors as well as Video Monitoring or “Electronic Sitters” for patients at high risk for suicide.

Full content available HERE





The Joint Commisssion

  • Issued November 26, 2018; updated February 20, 2019

Prepublication Requirements

The Joint Commission has approved the following revisions for prepublication. While revised requirements are published in the semiannual updates to the print manuals (as well as in the online Edition®), accredited organizations and paid subscribers can also view them in the monthly periodical The Joint Commission Perspectives®. To begin your subscription, call 800-746-6578 or visit


Please note: Where applicable, this report shows current standards and EPs first, with deleted language struck­ through. Then, the revised requirement follows in bold text, with new language underlined.



Effective July 1, 2019


Identify individuals at risk for suicide.

Reduce the risk for suicide.


                       Elements of Performance for NPSG.15.01.01



  1. Conduct a risk assessment that identifies specific characteristics of the individual served and environmental features that may increase or decrease the risk for suicide.


  1. The organization conducts an environmental risk assessment that identifies features in the physical environment that could be used to attempt suicide; the organization takes necessary action to minimize the risk(s) (for example, removal of anchor points, door hinges, and hooks that can be used for hanging).

Note: Noninpatient behavioral health care settings and unlocked inpatient units do not need to be ligature-resistant. The expectation for these settings is that they conduct a risk assessment to identify potential environmental hazards to individuals served; identify individuals who are at high-risk for suicide; and take action to safeguard these individuals from the environmental risks (for example, removing objects from the room that can be used for harm and continuous monitoring in a safe location while awaiting transfer to higher level of care).

  1. Address the immediate safety needs and most appropriate setting for treatment of the individual served.


  1. Screen all individuals served for suicidal ideation using a validated screening


  1. When an individual at risk fur suicide leaves the care of the organization, provide suicide prevention information (such as a crisis hotline) to the individual and his or her family.


  1. Use evidence-based process to conduct a suicide assessment of individuals served who have screened positive for suicidal ideation. The assessment directly asks about suicidal ideation, plan, intent, suicidal or self-harm behaviors, risk factors, and protective factors.

Note: EPs 2 and 3 can be satisfied through the use of a single process or instrument that simultaneously screens individuals served for suicidal ideation and  assesses the severity of suicidal ideation.


  1. Document individuals’ overall level of risk for suicide and the plan to mitigate the risk for suicide.


  1. Follow written policies and procedures addressing the care of individuals served identified as at risk for suicide. At a minimum, these should include the following:
    • Training and competence assessment of staff who care for individuals served at risk for suicide
    • Guidelines for reassessment
    • Monitoring individuals served who are at high risk for suicide


  1. Follow written policies and procedures for counseling and follow-up care at discharge for individuals served identified as at risk for


  1. Monitor implementation and effectiveness of policies and procedures for screening, assessment, and management of individuals served at risk for suicide and take action as needed to improve compliance.




Additional FAQs: Suicide Risk Reduction Recommendations

The November 2017, January 2018, and July 2018 issues of Perspectives published suicide risk reduction recommendations from an expert panel convened by The Joint Commission. On October 9, 2018, The Joint Commission convened the sixth expert panel to further address questions related to these recommendations. The following set of Frequently Asked Questions (FAQs) is intended to clarify the panel’s recommendations to reduce the risk of suicide in health care settings.

For questions related to the FAQs or the suicide risk recommendations please contact the Standards and Interpretation Group (SIG) via the Standards Online Submission Form.

QUESTION: Are dropped ceilings allowed in corridors and common areas on an inpatient psychiatric unit?

ANSWER: Yes, dropped ceilings are allowed in corridors and common areas where staff are regularly present as allowable by the facility’s safety risk assessment.  These areas do not need to be in constant view of staff but should be a part of the standard safety rounds conducted by staff (for example, 15-minute patient safety checks, shift-to-shift environmental rounds, and so on).

Dropped ceilings in areas that are not fully visible to staff (for example, a right-angle curve of a corridor) should be noted on the risk assessment and have some additional steps taken to make it more difficult for a patient to attempt to access the space above the dropped ceiling (such as gluing or clipping tiles), which would allow staff to hear or see the patient’s suicide attempt and prevent the attempt from occurring.

QUESTION: Has The Joint Commission identified any specific items that should not be allowed to be brought on an inpatient psychiatric unit?

ANSWER: No, The Joint Commission does not determine the items to be prohibited from an inpatient psychiatric unit. Items that ore prohibited to be brought into organizations, due to the risk of harm to self or others, should be determined by the organization. Compliance with such safety measures is based upon organizational policies/procedures, individual core plans, and applicable state rules or regulations.

QUESTION : Does The Joint Commission recommend specific ligature-resistant products?

ANSWER: No, The Joint Commission does not recommend products.  Organizations are required to do the following:

  • Comply with the Recommendations for Suicide Prevention in Healthcare Settings (see the previously fisted Perspectives articles)
  • Conduct a risk assessment of the environment
  • Determine which products to appropriately install (based on manufacturersinstructions)
  • Ensure that the products are functioning properly to maintain ligature resistance P

 Perspective’s, January 2019, Volume 39, Issue1


The Joint Commission has released a Frequently Asked Questions (FAQ) that contains responses to inquiries that have been submitted regarding their Recommendations Regarding Environmental Hazards for Providers and Surveyors in several editions of their Perspectives newsletter starting in November of last year.  The FAQs are in the July 2018 edition of Perspectives.

Full text of the FAQ section is now available CLICK HERE


The January 2018 issue of The Joint Commission’s Perspectives addresses the recommendations that came from the Expert Panel’s third meeting  (October 2017) regarding ligature attachment and other risks in non-hospital settings such as:

  • Residential Treatment
  • Partial Hospitalization
  • Intensive Outpatient
  • Outpatient Treatment

The three new recommendations, (#14-16) state that these settings:

#14. Are not required to be ligature resistant.

#15. An environmental safety risk assessment must be performed for staff training purposes.

#16. Policies and procedures for managing patients who may be escalating and for whom self-harm may be an issue while waiting for transfer to a higher level of care.

NOTE: Both James M. Hunt and David M. Sine are members of, and active participants in, this Expert Panel.

November 2017 Perspectives: SUICIDE PREVENTION in HEALTH CARE SETTINGS: Recommendations Regarding Environmental Hazards for Providers and Surveyors

The Joint Commission has released their recommendations regarding Hospital Environmental

Hazards for Providers and Surveyors.  In an attempt to get this information circulated quickly, and with concern that the exact wording be communicated, please click on the link below and again on the link on the following page read the article in the, “The Joint Commission Perspectives”, November 2017, Number 11.