TJC & CMS News Blog
Information for

TJC has published proposed revisions to the National Patient Safety Goal (NPSG) on suicide risk assessment for both the Hospital Accreditation Program and the Behavioral Health Care Accreditation Program. The proposed revisions are out for field comment which ends on May 1. Highlights are as follows:

There is a new focus on the use of evidence based tools for both screening of suicide risk and assessment of suicide risk. Examples of evidence based screening tools and evidence based assessment tools are listed in the elements of performance and include:

Screening Tools

  • Suicide Behaviors Questionnaire-Revised (SBQ-R) (for BH and Hospitals)
  • Emergency Medicine Network’s ED-SAFE Patient Safety Screener for emergency departments (for Hospitals only)

Assessment Tools

  • Columbia-Suicide Severity Rating Scale (C-SSRS) (for BH and Hospitals)
  • Suicide Prevention Resources Center’s Decision Support Tool (for BH and Hospitals)
  • Emergency Medicine Network’s ED-SAFE Patient Safety Secondary Screener for emergency departments (for Hospitals only)
  • SAFE –T Pocket Card (for Hospitals only)

Unlike the current NPSG, the proposed revisions explicitly describe the option for a two-step process whereby patients are first screened for suicide risk and, if the screening is positive, then receive a full assessment of suicide risk. This emphasis on a two-step process is primarily applicable to emergency departments of med/surg hospitals who would do this type of screening in the ED. Freestanding psychiatric hospitals and behavioral health organizations, of course, do not have EDs and thus typically conduct a full suicide risk assessment on all patients (instead of a screening first and full assessment if indicated.)

In addition, the following language of the current NPSG is deleted: “Conduct a risk assessment that idnitfies specific patient characteristics and environmental features that may increase or decrease the risk for suicide.” Presumably, the evidence based tools that would be used include both risk factors and protective factors as required by the current language.

The requirement in the current NPSG to provide information on suicide prevention to patients being discharged is broadened to require policies and procedures that address how patients with suicide risk will be managed within the organization or transferred and how family members will be notified.

There is also a new monitoring requirement added whereby the organizations must monitor (i.e. collect data) on their suicide risk assessment process and related policies and then take action to improve compliance. This means including it in your ongoing PI program.

The comment period ends May 1 so we encourage you to provide input ASAP on this important topic. (The proposed revisions came out on March 20 – too late for our March newsletter.) To comment, see the Field Review pages on the TJC website:

Hospital Accreditation Program Field Review

Behavioral Health Care Accreditation Program Field Review