In the realm of Behavioral Health Care (BHC) organizations, creating a safe and supportive environment is paramount. However, several physical environment challenges pose challenges that demand careful attention and mitigation strategies to ensure the well-being of both staff and individuals served in both Hospitals  and  Behavioral Health Care organizations.  Establishing a safe behavioral health environment begins with conducting a robust environmental risk assessment.

According to The Joint Commission‘s 2022 survey data, the leading deficiency in the physical environment across BHC organizations revolves around National Patient Safety Goal (NPSG) Standard NPSG.15.01.01, Element of Performance (EP) 1. This EP mandates that the organization conducts an environmental risk assessment to identify potential suicide hazards in the physical environment and take necessary actions to minimize these risks.

Joint Commission Surveyors Frequently Cite NPSG.15.01.01 EP 1 

Notably, this requirement has consistently ranked high for noncompliance since 2019, reflecting its significance in suicide prevention efforts. In 2022 alone, out of 1,811 surveyed BHC organizations, 101 were flagged for high-risk deficiencies, while 353 received moderate-risk citations related to this EP. The focus on suicide prevention is well-founded, with patient suicide being the fifth leading sentinel event type in 2022, according to The Joint Commission’s Sentinel Event Data 2022 Annual Review.

Common Joint Commission Findings

Common findings from The Joint Commission’s database under NPSG.15.01.01, EP 1, include:

• Lack of evidence that environmental risk assessments were conducted.
• Failure to mitigate identified environmental risks.
• Incomplete implementation of environmental risk mitigation measures.
• Neglecting to remove objects that pose a risk for self-harm.
• Use of non-ligature-resistant hardware.
• Providing unsupervised access to potentially dangerous items.

Key Components of an Effective BHC Environmental Risk Assessment:

To address these challenges effectively, organizations must prioritize a thorough environmental risk assessment. This involves tailoring the risk assessment to the specific BHC setting.  

• Multidisciplinary Team Involvement:  Form a multidisciplinary team that includes professionals from various disciplines, such as clinicians, facility managers, safety officers, and administrators. Each member should bring a unique perspective to the assessment.
• Documentation and Review:  Gather and review all relevant documentation related to the facility’s physical environment. This may include building plans, maintenance records, safety protocols, and previous assessments.
• Site Inspection:  Conduct a thorough on-site inspection of the facility, including patient rooms, common areas, treatment rooms, and outdoor spaces. Pay close attention to any potential hazards that could be used for self-harm or pose safety risks.
• Identify Potential Hazards:  Identify all potential environmental hazards that could be used to attempt suicide or self-harm. This includes items like anchor points, door hinges, hooks, furniture, fixtures, and potential ligature points.
• Risk Assessment:  Assess the level of risk associated with each identified hazard. Consider factors such as the accessibility of the hazard, the severity of potential harm, and the likelihood of exposure.
• Prioritization:  Prioritize hazards based on their level of risk. Focus on addressing high-risk hazards first, but do not neglect lower-risk ones.
• Mitigation Strategies:  Develop and implement mitigation strategies for each identified hazard. These strategies may include removing, modifying, or replacing hazardous items, ensuring the use of ligature-resistant fixtures, and improving supervision or monitoring in high-risk areas.

Continuous Improvements that Minimize Physical Environment Challenges

After evaluating risks, implement steps to maintain process improvements that minimize physical environment challenges.

• Continuous Monitoring:  Establish a system for continuous monitoring of the physical environment to ensure that mitigation strategies remain effective over time. Regular inspections and audits should be conducted to identify and address any new hazards that may arise.
• Staff Training and Education:  Provide training and education to staff members on recognizing and reporting environmental risks. Staff should be aware of the importance of their role in maintaining a safe environment.
• Documentation and Reporting:  Maintain detailed documentation of the risk assessment process, including hazard identification, risk level assessments, and mitigation strategies. Report findings and progress to relevant stakeholders, including leadership, accreditors, and regulatory authorities.
• Regular Updates and Reassessment:  Environmental risk assessments should be a dynamic process. Regularly update the assessment as the physical environment changes and reevaluate the effectiveness of mitigation strategies. This ensures ongoing safety and compliance.
• Collaboration with Accreditation and Regulatory Agencies:  Collaborate with the Joint Commission, CMS, State agencies and other regulatory bodies, to ensure compliance with specific standards and requirements related to environmental risk assessments.

An effective BHC environmental risk assessment is an ongoing process that involves a commitment to maintaining a safe and therapeutic environment for individuals receiving care. It requires collaboration, vigilance, and a proactive approach to identifying and mitigating potential risks.  Find additional resources on the Joint Commission Suicide Prevention Portal.

Barrins & Associates Consultation

Barrins & Associates have expert Life Safety Consultants available to assist your organization in developing and implementing a custom robust Environmental Risk Assessment.  We can provide a focused consulting engagement or incorporate an Environmental Risk Assessment into a Mock Survey or Continuous Readiness Consultation. We continue to be your partner in achieving and sustaining Joint Commission Accreditation and regulatory compliance.