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Heads up for behavioral healthcare organizations surveyed under the Behavioral Health Care standards! TJC just issued an important clarification on revised National Patient Safety Goal 15.01.01 for non-inpatient BH settings.

Revised NPSG.15.01.01

The revised National Patient Safety Goal on suicide risk reduction goes into effect July 1, 2019. We covered these revisions in our recent post National Patient Safety Goal NPSG.15.01.01: Q&A on New Requirements.

Subsequently, several readers posed questions about Element of Performance # 1 for organizations surveyed under the TJC Behavioral Health Care standards. This EP states the following: “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.”

Questions from Readers

We received several inquiries from behavioral healthcare organizations that are not psychiatric hospitals. These BH organizations questioned whether this EP required their environments to be ligature resistant. They pointed out that such a requirement would be inconsistent with previous guidance from TJC.

TJC’s previous guidance had indicated that non-inpatient BH settings do not need to be ligature resistant. These settings must conduct an environmental risk assessment to identify potential safety hazards.

They must also make decisions about any items they think should be removed from the environment. Lastly, they must train staff on the environmental risks and how to keep clients safe if they decompensate and need transfer to a higher level of care. See our post Suicide Prevention Recommendations for Non-Hospital Behavioral Health Settings.

Clarification from TJC

In follow-up, we discussed this issue with TJC at the recent Consultants Forum meeting at TJC headquarters. They affirmed that the intent of the revised National Patient Safety Goal was NOT to require non-inpatient BH settings to be ligature resistant.

As a result, TJC has clarified the intent of NPSG.15.01.01 EP 1 for behavioral healthcare organizations that are not psychiatric hospitals. They have officially added a Note to EP 1 to clarify its applicability to non-inpatient BH settings.

The Note reads as follows: “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 self-harm and continuous monitoring in a safe location while awaiting transfer to a higher level of care.”

The full text of the revised NPSG.15.01.01 – including the new Note for EP 1 – is on the Joint Commission website under Prepublication Requirements.

Ligature Risk Survey Findings for BH Organizations

A common finding we see on TJC surveys of non-inpatient BH settings is that the organization has not conducted an environmental risk assessment to identify ligature and self-harm risks. Many organizations are aware of the risks and can discuss them but don’t have a written document to show surveyors.

When we conduct our mock surveys, we provide consultation on how to conduct this type of environmental risk assessment. We have a template we share with our clients to document the assessment. Once completed, this provides a written document the organization can share with surveyors. This has worked well for our clients on their surveys.

Survey Readiness: What to Do Now

In summary, if you’re a non-inpatient BH setting, make sure you’ve implemented TJC’s recommendations for this level of care. These are as follows:

  1. Conduct a risk assessment to identify elements in the environment that clients could use to harm themselves, visitors, and/or staff. Remove items that have high potential to be used to harm oneself or others. Place them in a secure location when possible.
  2. Train staff to be aware of elements in the environment that pose a serious risk to clients who could develop suicidal ideation. Educate staff on how to keep a client safe from these hazards until the client is stabilized or transferred to a higher level of care.
  3. Develop and implement policies and procedures on how to manage a client in these levels of care who may experience an increase in symptoms that could result in self-harm or suicidality.

Furthermore, make sure you can show surveyors evidence of how you’ve implemented these recommendations. That should include the documented environmental risk assessment, evidence of staff training, and written policies on managing clients who decompensate. As a result, you’ll not only have a smooth survey experience. You’ll have made the environment a safer place for your clients and staff!