If you are a psychiatric hospital anticipating a TJC survey, it’s important to know the details of how TJC is currently surveying ligature risks. They recently provided an update for the field on this topic in follow-up to their March 2017 communication on the scoring of ligature, suicide and self-harm risks. The following are highlights from this most recent update.

  • Psychiatric hospitals and psychiatric units of med/surg hospitals are now considered “dedicated” spaces; i.e. “spaces in which patients at risk for suicide are preferentially cared for regardless of how much the space is used for other patients.” These dedicated spaces need to be “ligature and suicide risk free.”
  • Surveyors will evaluate the following during surveys:
    • The organization’s environmental risk assessment
    • Policies/procedures for mitigating risks and how effective these have been
    • Staffing patterns
    • How safety precautions are implemented for those identified at risk
    • Internal PI efforts on addressing and eliminating risks.
  • Each observation of a ligature or suicide risk will result in a Requirement for Improvement (RFI) and will be scored at EC.02.06.01 EP 1. These RFIs will be rated as High Risk on the SAFER matrix and either Limited, Pattern, or Widespread in scope dependent on the number of observations.
  • Surveyors will discuss their observations with the organization to assess awareness of these risks and the organization’s mitigation efforts. Any environmental risk that is ongoing will be scored as an RFI along with the organization’s mitigation efforts. A Condition level deficiency may be cited based on the degree and scope of the risk.
  • An Immediate Threat to Life (ITL) may be scored on the SAFER matrix for the following scenarios:
    • Highest level risks have been unrecognized or known risks have been inadequately mitigated.
    • Identified risks were not corrected after a sentinel event.
    • Environmental hazards have gone uncorrected over a long period of time.

In these instances, an acceptable safety plan will need to be developed before the survey team exits.

Related to this scrutiny on environmental risks, there is also a change to the scoring of the National Patient Safety Goal on suicide risk assessment (NPSG 15.01.01.) Findings for this NPSG will be cross walked to the CMS Patients’ Rights Condition of Participation (CoP) related to the patient’s right to care in a safe setting. Dependent on the scoring on the SAFER matrix, the finding(s) may result in a Condition level deficiency.

So, it’s now more important than ever that you be able to show a comprehensive, written document to surveyors that details the risk assessment you have conducted. Equally as important, you also need to be able to show the surveyors a detailed mitigation plan for any risks that have been identified but have not yet been eliminated.

For more information on how ligature risks will be surveyed, view the FAQ posted on June 1, 2017, on the TJC website.


TJC HR Requirement: Competence Assessment by a Qualified Individual Welcome Spring Harbor Hospital