It’s now been seven months since the new requirements for NPSG 15 on Suicide Risk Reduction took effect on July 1st. So, how is this important topic playing out on surveys?

First, we know surveyors are closely scrutinizing each of the seven elements of performance (EPs.) Moreover, they’re writing Requirements for Improvement for all seven EPs. Let’s take a look at some recent survey findings. And what you can do to avoid similar findings on your surveys.

NPSG 15: Linking Interventions to Suicide Risk Level

Surveyors cited several organizations for not identifying specific interventions based on the patient’s level of suicide risk.

Sample Survey Finding: In 4 out of 15 patients reviewed, clinicians rated patients as high suicide risk at admission based on the C-SSRS scale. There was no consistent process or protocol in the medical records identifying the specific interventions.

The take-away here is that once you’ve identified the patient’s risk level (high, moderate, or low) you need to specify interventions to mitigate that risk.

Strategy for Compliance: Be sure to include in your treatment plans the various interventions you’re providing for a moderate or high risk patient. These might include a heightened level of observation, suicide precautions, daily reassessment, and any other interventions you’re conducting to mitigate the risk.

A best practice we’ve seen at several organizations is a written protocol that lists the specific interventions for the various risk levels. For example, one organization automatically assigns the following interventions for a high risk patient:

• 1:1 arm’s length level of observation (including bathroom)
• No loopable clothing items (laces, strings)
• Daily room search
• Every shift reassessment of suicide risk
• Safety plan at discharge

NPSG 15: Staff Training

Another common survey finding relates to staff training on the suicide risk assessment process. Surveyors not only want to see that you’ve trained staff. They also want to see you’ve assessed the competence of the staff.

Sample Survey Finding: The organization had recently implemented the C-SSRS. They conducted a staff training session on the tool. However, there was no competency assessment documented. Record review showed staff had incorrectly scored three of ten suicide risk assessments.

Strategy for Compliance: Make sure you build a competency assessment component into your staff education and training. That should include a post-test as well as review of medical records to evaluate whether staff are correctly using the tool.

NPSG 15: Performance improvement Monitoring

Surveyors are beginning to cite organizations for not evaluating suicide risk reduction as part of the organization’s PI program.

Sample Survey Finding: The organization had not included suicide risk reduction in their Quality Assessment/Performance Improvement Plan. Leadership failed to monitor implementation of policies and procedures for suicidal patients.

Strategy for Compliance: First, determine what performance indicators you will use to evaluate compliance with your suicide risk reduction policy. Start with just two or three indicators. You can use data from chart reviews to evaluate the timeliness of assessments, the link between suicide risk level and interventions, and completion of safety plans at discharge.

Resources on TJC Website

TJC has all its FAQs on Suicide Risk Reduction on its website. Just click on the Standards tab. Then 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 Suicide Risk Reduction: Be Clear on TJC’s New July 1 Requirements and Suicide Risk Reduction: Two New FAQs from TJC.

We do a deep dive on suicide risk reduction during our Mock Surveys and Continuous Readiness Consultations. The agenda always includes suicide risk tracers. We also provide education on the new 2019 requirements. And how to link suicide risk assessment to treatment planning for an effective patient safety program.