Be prepared! TJC’s new requirements for the National Patient Safety Goal on Suicide Risk Reduction (NPSG.15.01.01) officially went into effect July 1st.
As anticipated, surveyors are closely evaluating compliance with the seven new requirements. We analyzed our clients’ survey findings since July 1st on this standard. There are already some clear themes emerging. So, here’s some feedback on what we’re seeing in the field.
NPSG.15.01.01 Evidence Based Suicide Risk Assessment
Surveyors cited several organizations for not conducting an evidence based suicide risk assessment. They had conducted the suicide risk screening with a validated tool. However, they didn’t go the next step and conduct the full risk assessment for patients who scored moderate or high on the screen.
Remember:TJC has defined what they mean by an evidence based suicide risk assessment process. Their FAQ defines it as “use of an evidence-based assessment tool, in conjunction with clinical evaluation.” We recommend you study that FAQ closely so you’re clear on the requirements.
If you don’t use an evidence based suicide risk assessment tool, you must meet certain conditions. TJC spells those out in their FAQ. We also covered this in our recent post NPSG.15.01.01 Suicide Risk Reduction: Get Clear on New Requirements.
Interventions for Suicide Risk
Notably, surveyors didn’t just scrutinize the suicide risk screening and assessment process. They also expected to see treatment interventions for patients with suicide risk. Frequently, they cited instances where the patient was moderate or high risk but the treatment plan didn’t include interventions to mitigate that risk.
Remember: Include in your treatment plans the various interventions you’re providing for a moderate or high risk patient. These could include a heightened level of observation, suicide precautions, and any other things you’re doing to mitigate the risk.
Lack of Written Policies
Several organizations were unaware they needed written policies on suicide risk assessment and care of at-risk patients. As one Clinical Director reported “We were OK on our clinical process but the surveyors wanted that all spelled out in a policy. Including how we were training our staff.”
Remember: NPSG.15.01.01 EP 5 requires a written policy that addresses the following:
- How you train staff on suicide risk assessment and assess their competence
- Your process for assessing and reassessing patients for suicide risk
- Your process for monitoring patients at high risk for suicide
No PI Monitoring
Surveyors cited quite a few organizations for not monitoring adherence to their own policies for suicide risk assessment and treatment of at-risk patients. Findings such as the following were common: “Suicide risk reduction was not included in the organization’s overall QAPI Plan. Leadership failed to monitor the implementation of policies and procedures related to the management of suicidal patients.”
Remember: NPSG.15.01.01 EP 7 requires that you collect data to evaluate how well you’re complying with your suicide risk reduction policies. You should review that data as part of your organization-wide PI program. And make improvements based on the results of your monitoring.
Close Scrutiny of all 7 Elements of Performance
Overall, the biggest takeaway from these recent surveys is that surveyors are closely scrutinizing each of the seven elements of performance in this standard.
NPSG.15.01.01 Resources on TJC Website
TJC now has all the FAQs on Suicide Risk Reduction on its website. Just click on the Hospital or Behavioral Health manual and find 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!
NPSG.15.01.01 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.
When we conduct our Mock Surveys and Continuous Readiness Consultations, we do a deep dive on suicide risk reduction. We always include a suicide risk tracer. We also provide education on the new 2019 requirements. And how to link suicide risk assessment to treatment planning.
We’ll continue to keep you posted on how the new requirements play out on surveys. And how you can best meet them and ensure patient safety in your organization.