February 2019 Perspectives: REVISIONS to the NATIONAL PATIENT SAFETY GOAL on REDUCING the RISK for SUICIDE

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 http://www.jcrinc.com.

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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.

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APPLICABLE TO THE BEHAVIORAL HEALTH CARE ACCREDITATION PROGRAM

Effective July 1, 2019

NPSG.15.01.

Identify individuals at risk for suicide.

Reduce the risk for suicide.

 

                       Elements of Performance for NPSG.15.01.01

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  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.