Joint Commission has made significant changes to their definition of a sentinel event related to suicide. These changes, set to take effect on January 1, 2024, have surprised organizations because TJC typically provides a generous six-month notice for alterations to requirements, as per the accreditation contract between your organization and TJC. However, this time, it seems TJC has deemed this change a patient safety imperative, necessitating a more expedited timeline. Additionally, while it might initially appear to be a policy matter, it becomes a crucial standards issue within LD.03.04.09, EP 4, which mandates that your sentinel event policy align with TJC’s.

Suicide Sentinel Event Previous and New Definitions

Previously, TJC defined a suicide sentinel event as a suicide occurring in a 24-hour staffed setting or within 72 hours of discharge from that setting, or within 72 hours of discharge from the emergency department. However, with the impending changes, the definition will broaden its scope to include suicides within 7 days of discharge from a 24-hour setting or the emergency department. Notably, the new definition will explicitly cover suicides occurring within 7 days of discharge from day treatment, partial hospitalization, intensive outpatient, residential, group home, and transitional supportive living facilities.

Implications and Urgency

With 2024 right around the corner, it’s imperative for readers, especially those anticipating surveys in the first quarter of 2024, to promptly revise their sentinel event policies and definitions to align with these revised requirements.  The January E-Edition already incorporates these new stipulations. As you embark on your policy analysis and revisions, it’s wise to scrutinize all definitions to ensure that your policy adjustments encompass other changes made by TJC over the past few years.

Additional Changes to Terminology and Definitions

It’s important to note that, beyond the changes related to suicide sentinel events, TJC has introduced various terminology and definition modifications in recent years. These changes include:

• November 2019: Updates to the definitions of invasive procedure, hemolytic transfusion reaction, and fire-related incidents.
• June 2020: A revised definition for falls.
• December 2020: Categorization changes for rape, assault, and homicide incidents.
• October 2022: An updated definition for sexual assault and abuse.

Voluntary Reporting and Compliance

While it’s important to know that reporting sentinel events remains voluntary, it’s equally essential to understand that compliance with requirements hinges on aligning your organization’s sentinel event definitions with TJC’s. Your organization has the flexibility to adopt a broader definition from TJC’s, but it cannot impose a narrower one. Therefore, it is incumbent upon you to review and edit your policy to ensure that it mirrors the current definitions outlined in the Sentinel Event chapter.

Take Action Now

In light of the impending changes to TJC’s definition of suicide sentinel events, organizations should act swiftly to update their policies and definitions. Staying consistent with TJC’s standards is not only a regulatory requirement but also a proactive step towards improving patient safety and quality of care.

Barrins & Associates Consultation

At Barrins & Associates we can assist you to achieve ongoing compliance that align your sentinel event definitions with TJC.  Inquire today about our consulting services.  We continue to support your journey toward accreditation and regulatory compliance.  

 We continue to be your partner in achieving and sustaining Joint Commission Accreditation and regulatory compliance.