TJC has proposed revisions to the current National Patient Safety Goal on suicide risk assessment (NPSG.15.01.01) for both the Hospital and Behavioral Health Care Accreditation Programs. The proposed revisions are available for comment until May 7, 2018. The following is a summary of the revisions:

• There is a change from the more narrow focus on suicide risk assessment to the broader focus of reducing suicide risk. The NPSG is reworded to say “Reduce the risk for suicide.”
• The NPSG is also broadened to include reference to the organization’s environmental risk assessment and how suicide risks are minimized in the physical environment. (EP # 1)
• A “validated screening tool” is required to be used for all patients being evaluated or treated for behavioral health conditions as their primary reason for care. (EP # 2)
• An “evidence-based” suicide risk assessment must be conducted for patients who screen positive for suicidal ideation. (EP # 3)
• The patient’s overall level of risk for suicide must be documented as well as the plan to mitigate that risk. (EP # 4)
• Written policies and procedures are required to address the following topics: (EP 5, 6)
  • Training and competency assessment of staff who treat patients at risk for suicide
  • Guidelines for the reassessment of patients
  • Monitoring patients who are at high risk for suicide
  • Referral for counseling and follow-up care at discharge for patients identified at risk for suicide.
• There is also a new requirement to monitor the implementation and effectiveness of policies/procedures for assessing and managing patients at suicide risk. This will require determining what aspects of your process you will measure; how you will collect data; and how that data will be analyzed. Essentially, these measures will need to be a part of your organization’s overall PI process.

The primary thrust of the proposed revisions is to bring a more comprehensive approach to suicide risk assessment and management including use of evidence-based tools, staff training, consistent policies, and monitoring of the process to ensure its effectiveness.

Since this topic is of such importance to all types of behavioral health organizations, we encourage you to review the proposed revisions in detail and provide comments to TJC by the May 7^th deadline. Once the changes are final, we’ll all be living with them for the foreseeable future. See the TJC website for the full text of the proposed revisions and how to submit comments.