TJC & CMS News Blog
Information for

As we know, suicide risk assessment continues to be a high focus area for The Joint Commission. (See our recent posts Suicide Risk Reduction Tracer  and High Risk Areas for Joint Commission Surveys.) Accordingly, TJC will further strengthen its approach to suicide risk reduction in 2019 and revise National Patient Safety Goal NPSG.15.01.01. As a result, the expanded NPSG.15.01.01 will require organizations to do the following:

Assess and Mitigate Environmental Risks

The revised NPSG.15.01.01 will include the requirements for environmental risk assessment and removal of ligature risks. Currently, these requirements are in the Environment of Care standards.

Screen for Suicidal Ideation

Screen all patients for suicidal ideation who are being evaluated or treated for behavioral health conditions. Also, use a validated screening tool.

Assess Suicide Risk

For patients who screen positive for suicidal ideation, conduct a suicide risk assessment. Directly ask about suicidal ideation, plan, intent, suicidal or self-harm behaviors, risk factors, and protective factors. (Organizations can use a single instrument to simultaneously screen patients and assess the severity of suicidal ideation.)

Document Risk Level and Mitigation Plan

Documentation should include interventions directly related to the patient’s level of suicide risk. These could include level of observation, precautions, and other interventions aimed at reducing the suicide risk.

Monitor High Risk Patients

Develop written policies/procedures for monitoring high risk patients. Include training and competence assessment of staff and guidelines for reassessment.

Care at Discharge

Follow written policies/procedures for counseling and follow-up care at discharge. (Notably, this is the first time the discharge process is being included in this National Patient Safety Goal.)

Performance Improvement

Monitor the effectiveness of procedures for screening, assessment and management of at-risk patients. Take action as needed to improve compliance.

Preparing for the Revised National Patient Safety Goal NPSG.15.01.01

In summary, the revised National Patient Safety Goal aims not only to help reduce the risk of inpatient suicide. It also extends to the process of care coordination at the point of discharge. Admittedly, this is a broader but equally important challenge.

So, now is a good time to review your current process for suicide risk assessment and management in light of these expanded requirements. We will keep you abreast of further developments on this topic in upcoming posts.

Be sure to also read the article in the October TJC Perspectives “Report: Incidence and Method of Suicide in Hospitals in the U.S.” It summarizes the full article on the same topic in the Joint Commission Journal on Quality and Safety. The study provides important data on where and how suicides occur in hospitals that is critical for informing continued risk reduction efforts on this front.