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NPSG 15 Suicide Prevention: Training & Competency Requirements

Feb 6, 2022 by
, , , BH Organizations, Hospitals

NPSG 15 Suicide Prevention Training & Competency Illustration

As we know, compliance with TJC’s National Patient Safety Goal 15 on Suicide Prevention continues to be a challenge for many organizations. Survey findings related to inadequate suicide risk assessment abound.

But what about the requirements for training and competency assessment for your staff who conduct suicide risk assessments? Recently, we’ve seen an increase in the number of survey findings for this requirement. Here’s a few examples from survey reports:

“Reviewed six competency files of staff who care for suicidal patients. There was no documentation of training and competence assessment related to care of the suicidal patient, including completion of the suicide risk assessment.  This was confirmed by the Director of Human Resources.”

“There was no documentation of any formal, organized training for nursing staff who conduct the suicide risk assessment.”

So, let’s take a look at just what TJC requires in terms of training and competency assessment for suicide prevention.

NPSG 15 Element of Performance # 5: Staff Training

The requirements for NPSG 15 EP 5 are the same in both the Hospital and Behavioral Healthcare & Human Services manuals. The only difference is the Hospital manual uses the term “patient” and the BH manual uses the term “individual served.”

Specifically, NPSG 15 EP 5 states: “Follow written policies and procedures addressing the care of patients identified as at risk for suicide. At a minimum, these should include the following:

  • Training and competence assessment of staff who care for patients at risk for suicide
  • Guidelines for reassessment
  • Monitoring patients who are at high risk for suicide.”

Thus, NPSG 15 clearly requires written policies and procedures that define how you train your staff on the suicide risk assessment process and how you assess their competence. So, developing that policy is the first step.

Next, you need to design the content for the training. At a minimum, that should include:

  • Training on your suicide risk assessment policy. Specifically, the steps in your suicide risk screening and assessment process and who completes the various components.
  • Training on the tools you use for suicide risk screening and assessment.
  • Training on the documentation requirements.

Many organizations now use an online Learning Management System for staff orientation and training. Several of these have excellent modules on suicide prevention and suicide risk assessment. For example, Relias has a module on Suicide Prevention Training: Identifying and Responding to Risk.

NPSG 15 EP # 5: Competency Assessment

Keep in mind: In addition to delivering training, you also need to assess your staff’s competence. That is, how well are they able to apply the concepts from the training?

Competency assessment can take several forms. It can include written tests as well as clinical supervision and review of clinical documentation.

TJC discusses the difference between education and training vs. competency in one of their FAQs. It states “Assessing competency is the process by which the organization validates, via a defined process, that an individual has the ability to perform a task, consistent with the education and training provided.”

In addition, there’s another helpful FAQ on competency assessment vs. orientation. This one provides guidance on how these two processes differ. Moreover, it clarifies exactly what you need to include in your orientation program.

Joint Commission Survey Process

During the Competency Assessment session of your survey, surveyors typically review Human Resources and Staff Education files. That’s where they expect to see documentation of both staff training and competence assessment.

Survey Strategy Tip: Make sure there’s a manager in that Competency Assessment session who knows where to find the documentation of training and competence assessment on suicide risk reduction.

Also, be prepared to show the content of your training modules. Surveyors frequently ask for this material.

Barrins & Associates Resources on NPSG 15

For more information and strategies for compliance with NPSG 15, see our earlier posts:

Additionally, TJC’s R3 Report Issue 18 National Patient Safety Goal for Suicide Prevention is a highly valuable resource. It details the specific requirements and provides links to many helpful references and tools. We use it frequently during educational sessions with our clients.

Barrins & Associates Consultation 

We’re now conducting our Mock Surveys and Continuous Readiness Consultations both virtually and onsite.

Most importantly, we’re covering all the updates to the 2022 Joint Commission standards and the 2022 survey process. As always, we’re prepared to support your ongoing compliance and survey readiness even in these continually challenging times.