Have you seen the latest FAQ from TJC on NPSG.15.01.01 – Suicide Risk Reduction? It’s about monitoring patients at high risk of suicide. Important information for everyone grappling with the new requirements effective 7/1/19.
New FAQ: Monitoring High Risk Patients
TJC issued their new FAQ on 11/14/19. It relates specifically to monitoring of patients at high risk of suicide. Here’s the question and the response in its entirety. The FAQ applies to both the Hospital and Behavioral Health manuals.
Q: “What is the monitoring requirement for patients at high risk for suicide?”
A: “In units/areas that contain ligature and/or other safety risks, patients determined to be at high-risk for suicide must be under continuous observation with the ability to immediately intervene through the use of 1:1 observation – 1 qualified staff member to 1 high risk patient. A qualified staff member is one that has been trained and has demonstrated competence in working with suicidal patients and performing 1:1 observation.
In inpatient psychiatric units/designated psychiatric areas that are ligature resistant and free from other safety risks, it is up to the organization to determine monitoring requirements for patients determined to be at high-risk for suicide and define such in their policy.”
NPSG.15.01.01: Interpreting the Latest FAQ
This latest FAQ appears to allow organizations more latitude in determining monitoring requirements for high risk patients. However, it’s important to keep several points in mind when interpreting this latest FAQ. Let’s be clear on what it says.
Areas with Ligature Risks
If the area contains ligature risks and/or other safety risks, patients at high risk for suicide need continuous 1:1 observation. That means one staff person to one patient.
Also, you must be able to demonstrate you’ve trained that staff person in doing 1:1 observation. Most importantly, that you’ve assessed their competence. Moreover, you need documentation of that training and competence assessment.
Ligature Resistant Areas
If the area is an inpatient psychiatric unit or a designated psychiatric area that is ligature resistant AND free from other safety risks, your organization can determine the monitoring requirements for patients at high suicide risk. Most importantly, you must define these monitoring requirements in your policy.
Best Guidance on NPSG.15.01.01 Compliance
When we work with clients on implementing the new requirements for NPSG.15.01.01, we always use TJC’s R3 Report Issue 18 on the National Patient Safety Goal for suicide prevention.
It clearly and concisely lays out each of the seven new requirements. Additionally, it provides a rationale and resources for each requirement. The R3 Report is a great teaching tool for your managers and staff.
Barrins & Associates Resources
To understand just how TJC is surveying compliance with the Suicide Risk Reduction National Patient Safety Goal, see our recent post NPSG.15.01.01 Suicide Risk Reduction: Feedback from Surveys.
We do a deep dive on suicide risk reduction when we conduct our Mock Surveys and Continuous Readiness Consultations. Our agenda always includes a suicide risk tracer. In addition, we provide education on the new 2019 requirements. And how to link suicide risk assessment to treatment planning.
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!
2020 TJC Surveys
Undoubtedly, suicide risk reduction will continue to be a major focus during 2020 surveys. Therefore, as the new year unfolds, we’ll keep you posted on new developments and survey trends to help you ensure patient safety in your organization. Stay tuned!