It’s official! The new requirements for TJC’s National Patient Safety Goal NPSG.15.01.01 on Suicide Risk Reduction became effective July 1st.
Predictably, surveyors are focusing intensely on these new requirements. We’ve seen survey reports that cite all seven elements of performance.
We recently discussed the new requirements firsthand with TJC leadership at the Consultants Forum meeting at TJC headquarters. We raised questions on a few areas where our clients are seeking clarification. We’ve captured the key points below and some insights on these new requirements.
NPSG.15.01.01: High Risk Patients Require 1:1 Monitoring
If you identify a patient as high risk for suicide, TJC expects you to implement constant 1:1 visual observation for that patient. This applies to both inpatient psychiatric settings and med/surg settings.
This level of observation requires an assigned, qualified staff member to observe the patient at all times. That staff member’s assignment should be to observe only one patient at a time. Rationale is the staff member would be able to intervene immediately if the patient attempted self-harm.
The use of video monitoring is not acceptable. Rationale is the staff member is not immediately available to intervene.
For further details, see TJC FAQ Ligature and Suicide Risk Reduction – Video Monitoring of Patients at High Risk for Suicide.
Validated Screening Tool
NPSG.15.01.01 EP # 2 requires you to screen all patients (being evaluated or treated for behavioral health conditions) for suicidal ideation. And you must use a validated screening tool.
A validated tool is one that has been scientifically tested for reliability, validity, sensitivity, and specificity. Examples of validated screening tools include the Columbia-Suicide Severity Rating Scale (C-SSRS) Screener version, the PHQ-2 , the Patient Safety Screener, the TASR Adolescent Screener, and the ASQ Suicide Risk Screening Tool.
For further details, see TJC FAQ Suicide Risk Reduction – Use of Validated Screening Tools.
Evidence Based Process for Suicide Risk Assessment
For patients who screen positive for suicide risk, you must conduct a suicide risk assessment. NPSG.15.01.01 EP 3 requires you to use an “evidence based process” for suicide risk assessment.
An evidence based process means you use an evidence based assessment tool along with a clinical evaluation. Key point here is that this is a two pronged process: (1) an evidence based assessment tool and (2) a clinical evaluation.
Additionally, this evidence based process must determine a level of suicide risk for the patient. This typically equates to a designation of high, moderate, or low risk.
Examples of evidence based assessment tools include the Columbia-Suicide Severity Rating Scale (C-SSRS) Lifetime-Recent version along with the C-SSRS Risk Assessment version and the Beck Scale for Suicide Ideation (BSI).
Non-Evidence Based Suicide Risk Assessment Tools
If you choose to use a suicide risk assessment tool that’s not evidence based, you must meet the following conditions:
- Demonstrate what evidence based resources the assessment is based on.
- The assessment must directly ask about suicidal ideation, plan, intent, suicidal or self-harm behaviors, risk factors, and protective factors.
- Document a clear synthesis as to how level of risk was determined.
For further details, see TJC FAQ Suicide Risk Reduction – Use of an Evidence Based Process to Assess Risk.
Assessing Protective Factors
A key part of the suicide risk assessment is assessing protective factors. The American Psychiatric Association defines protective factors as “characteristics that make it less likely that individuals will consider, attempt, or die by suicide.”
Keep in mind that protective factors may be present in two different spheres. First, they may be present in the patient’s family and/or community setting. Second, they may be present by virtue of being in a safe, structured, clinical setting such as an inpatient psychiatric unit. It’s important to consider both spheres when determining a patient’s level of risk.
The TJC FAQ Suicide Risk Reduction – Assessing Protective Factors provides examples of protective factors including:
- Safe, secure, monitored environment (e.g. inpatient hospitalization)
- Receiving clinical care for mental, physical, and substance abuse disorders
- Easy access to a variety of clinical interventions and support for help-seeking
- Family and community support (connectedness)
- Support from ongoing medical and mental health care relationships
- Skills in problem solving, conflict resolution, and nonviolent ways of handling disputes
- Cultural and religious beliefs that discourage suicide and support instincts for self-preservation
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!
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.
We do a deep dive on suicide risk reduction when we conduct our Mock Surveys. Our team always conducts 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.