The Joint Commission recently announced that it is increasing scrutiny during surveys on ligature, suicide and self-harm risks in psychiatric hospitals and inpatient psychiatric units of med/surg hospitals. Specifically, TJC surveyors will document in their report all observations of ligature or self-harm risks that they identify in the hospital’s environment. They will determine if the hospital has already identified these risks and, if so, what the action plan is to remove or mitigate these risks.

Based on our experience with this topic, you can anticipate surveyors will expect to see that the hospital has conducted a comprehensive environmental risk assessment with the following features:

  • It identifies specific features of the environment that pose a potential risk for suicide or self-harm.
  • It rates the severity of these risks.
  • It addresses how the risks will either be eliminated or mitigated.
  • It includes an action plan that identifies specific actions to be taken, timelines, and responsible parties.

As we know, TJC surveyors have been citing these types of environmental risks for awhile. The increased emphasis right now is in response to CMS’ heightened focus on suicide risks following a number of recent inpatient suicides.

Many psychiatric hospitals have made significant alterations to their physical environments to eliminate and reduce safety risks. Others are still a work in progress. The most common problem we see clients encounter during survey is that they are not able to show surveyors a comprehensive, documented environmental risk assessment that summarizes the risks and related action plans. Without this, the hospital cannot demonstrate that it is aware of the risks the surveyors have identified and that it is dealing with those risks.

So, if you have not yet conducted a formal environmental safety risk assessment, now is the time to do so. We recently updated the environmental risk assessment (PDF) that we compiled a few years ago from a variety of tools evaluable in the public domain and are happy to share that with our readers. Some other very useful tools for environmental risk assessment and safety products are the following:

The ECRI Institute Behavioral Health: Environmental Assessment 2016; available to members.

Design Guide for the Built Environment of Behavioral Health Facilities 7.1 (PDF), Updated April 2016

New York State Office of Mental Health Patient Safety Standards, Materials and Systems Guidelines (PDF), Updated January 2017


TJC Updates: Behavioral Health Care Accreditation Program Welcome Copper Springs