Is your organization ready for the revised NPSG.15.01.01 effective July 1, 2019? There are new and expanded requirements you’ll need to address. We reviewed these in our recent post NPSG.15.01.01: Changes Coming in 2019. This month, we’re responding to questions from our readers about some of the details of the new requirements. We thought it would be helpful to share those with you as you tackle this initiative in your organization.

Q: What’s different about the revised NPSG.15.01.01?

A: A key difference is the revised NPSG includes both the requirement for environmental risk assessment and clinical risk assessment. Previously, environmental risk assessment was addressed in the Environment of Care standards. The new goal also requires a “validated screening tool” and an “evidence based” assessment process. The current NPSG does not have these requirements.

Q: What does the revised NPSG.15.01.01 require for a suicide risk screening?

A: The revised NPSG requires that BH organizations, psychiatric hospitals, and psychiatric units in acute care hospitals screen all patients for suicidal ideation. As noted above, they must use a “validated screening tool.”

Q: Do we also have to do a suicide risk assessment in addition to the screening?

A: If the patient screens positive for suicidal ideation, you must conduct a suicide risk assessment. This assessment must directly ask about suicidal ideation, plan, intent, suicidal or self-harm behaviors, risk factors, and protective factors. You must use an evidence based process or instrument.

Q: Does the revised NPSG.15.01.01 require a two-step process for screening and assessment?

A: Organizations can use a two-step process: conduct the screening first and then, if indicated, conduct a full assessment. They can also use a single process to simultaneously screens for suicidal ideation and assesses the severity of suicidal ideation.

Q: Do we need to identify a level of suicide risk for the patient?

A: Yes. Based on the assessment, you must document the patient’s overall level of suicide risk. This is typically classified as high, medium, or low. You must also document the plan to mitigate the suicide risk. This information must be “explicitly documented” in the patient’s record.

Q: What suicide screening and assessment tools does TJC recommend?

A: TJC does not recommend or endorse any specific tools for suicide screening and assessment. The TJC R3 Report: Requirement, Rationale, Reference  cites several examples of tools and literature references that are very useful. Also, you can see the full text of the prepublication standards on the Joint Commission website.

Impact on Survey Process

Currently, surveyors closely scrutinize the suicide risk assessment process during tracers. (See our post Suicide Risk Reduction Tracer.) This scrutiny will undoubtedly ramp up when the new requirements go into effect. In fact, we’ve already seen surveyors applying the expanded requirements during recent surveys. So, be sure to take action quickly on the new provisions. You’ll be survey-ready and, more importantly, improve patient safety in your organization!