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NPSG.15.01.01 Suicide Risk Reduction: Safety Planning at Discharge

Oct 31, 2019 by
, , , BH Organizations, Hospitals

Discharge Planning Session NPSG.15.01.01 Suicide Risk Reduction.

Has your organization addressed the new NPSG.15.01.01.01 requirement for counseling and follow-up care at discharge? It went into effect July 1st. Interestingly, we find many clients focusing on the suicide risk assessment component but paying little attention to this other important requirement.

NPSG.15.01.01.01: Requirements at Point of Discharge

NPSG.15.01.01.01 Element of Performance (EP) # 6 requires organizations to “follow written policies and procedures for counseling and follow-up care at discharge for patients identified as a risk for suicide.” The rationale is that studies have shown the risk for suicide is high following discharge from a psychiatric hospital or an emergency room.

So, the first step in meeting this new requirement is to review your current processes for safety planning and discharge planning. After that, determine staff responsibilities and timelines for conducting these processes. In addition, be specific about how and where you will document the safety planning and the discharge planning you do with your patients/clients.

Lastly, make sure you describe all of this in a written policy and procedure. And be sure to train staff on their roles in implementing this policy and procedure.

A Best Practice for Safety Planning

Looking for a best practice for safety planning? The Safety Planning Intervention (SPI) is a brief intervention aimed at mitigating suicide risk. It includes a process for developing a written, prioritized list of coping strategies and resources patients can use to alleviate a suicidal crisis. The Suicide Prevention Resource Center has identified SPI as a best practice.

SPI employs a collaborative approach between the patient and the clinician. The product is a written Safety Plan the patient can use when he/she leaves the hospital setting. The Safety Plan includes the following components which are described in the patient’s own words:

  • Warning signs of an impending suicidal crisis
  • Internal coping strategies: Things I can do to take my mind off my problems without contacting another person
  • People and social setting that provide distraction
  • People whom I can ask for help
  • Professional or agencies I can contact during a crisis
  • Making the environment safe by restricting access to lethal means

The developers of SPI emphasize that the Safety Plan is not simply a form you give to a patient to complete on their own. Rather, it’s a collaboration between the patient and clinician. Together, they brainstorm ideas and develop the strategies that go into the Safety Plan.

NPSG.15.01.01.01: TJC Survey Process

Here’s some examples of how we see surveyors evaluating compliance on recent surveys. First, they request the policy on discharge planning. Subsequently, during tracers, they ask staff about discharge planning and who does what. Most importantly, they look for documentation in clinical records to show that staff is following the policy.

Once again, don’t overlook the importance of having a written policy. We recently saw two organizations that had the required processes in place but didn’t have a policy. As a result, the surveyors specifically cited them for this lack of a written policy.

NPSG.15.01.01 Resources on TJC Website

 All of the FAQs on Suicide Risk Reduction are on the TJC website. Just click on the Hospital or Behavioral Health manual and find the Standards tab. Go to the National Patient Safety Goals chapter. Use the keyword “suicide.” All the FAQs related to Ligatures and Suicide Risk Reduction are there in one easy-to-reference location.

Also, check out the TJC Suicide Prevention Portal on the TJC website. It has numerous tools for implementing the suicide risk reduction requirements. Great resources for improving patient safety in your organization!

Barrins & Associates Resources

 For additional background on the new NPSG 15 requirements, see our recent posts:

When we conduct our Mock Surveys and Continuous Readiness Consultations, we always include a suicide risk tracer. In addition, we provide education on the new 2019 requirements. Moreover, we cover how to link suicide risk assessment to treatment planning.

We’ll continue to keep you posted on how the new NPSG.15.01.01 requirements play out on surveys. Most importantly, how you can best meet them and ensure patient safety in your organization.