We all know the topic of suicide risk assessment is an important focus of TJC surveys in behavioral health settings — whether it’s an inpatient psychiatric unit or a community-based behavioral health program. You may not, however,  be aware that surveyors are instructed to conduct a specific tracer on suicide prevention in these BH settings. Surveyors have clear instructions on what to include in the scope of this tracer. So, here are some insights into what they’re expected to review and evaluate.

Crisis Process

How did the organization’s Crisis Team respond to and evaluate the patient?

Initial Assessment Process

How were the suicide risk screening and assessment conducted? How was the level of risk determined and how did that inform the treatment plan? If patients are placed on suicide precautions, what exactly does that mean? Is it defined in policy?  How do staff understand what they are expected to do for patients on suicide precautions?

Treatment Planning Process

How was the patient’s suicide risk addressed in the treatment plan? Is it defined as a problem on the treatment plan? Does the level of observation assigned for the patient correspond to the level of risk?

Reassessment Process

At what intervals was the patient’s suicide risk reassessed? Are the criteria and intervals for reassessment defined in policy and procedure? Are staff able to speak to those?

Continuum of Care

What is the communication and coordination process among staff relative to the patient’s suicide risk?

Human Resource Components

• Training: How have staff been trained to evaluate suicide and self-harm risks? If staff are implementing special precautions, how do they understand what that entails?
• Staffing: Is there sufficient staffing to implement heightened safety checks and special precautions? Are safety checks consistently and accurately documented?

Environmental Risks

What suicide and/or self-harm risks are present in the environment? Has the organization identified these on their environmental risk assessment? How are they mitigating these risks?

Feedback from our clients’ recent surveys reflects the increased intensity of this program-specific tracer. As one client related, “The surveyor’s focus on our suicide risk assessment process was much more intense than our last survey. She reviewed three records and did not like the fact that two of the three patients were determined to be at moderate suicide risk but were put on the same level of observation as the patient at low risk. We had long discussions about that. As a result, we’ve changed our process and created a more direct tie-in between the level of suicide risk determined at admission and the patient’s assigned level of observation.”

And from another client: “We were cited for the fact that the treatment plan did not directly address the client’s suicidal ideation. We included depression on the treatment plan, but that was not enough. The surveyor wanted us to directly address the suicide risk in the treatment plan and document the interventions related to that risk.”

Typically, we see findings related to an organization’s suicide risk assessment process (National Patient Safety Goal 15) scored in the upper right corner of the SAFER matrix indicating that the issue is high risk and widespread. So, we encourage you to be proactive and conduct internal tracers on this topic to see how you measure up to the expectations for this program-specific tracer. We always include these in our mock surveys. Often, we identify issues the organization can address to both improve the clinical process and avoid findings on the survey. That’s always a welcome outcome!