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For a few years now, TJC surveyors have been conducting suicide prevention tracers when applicable to the setting they are surveying. This is known as a “program specific tracer.” We recently had a client that had this type of tracer during their survey. We talked with them about their experience and thought it would be helpful to share their impressions. The setting was a psychiatric hospital and here’s the feedback from the survey coordinator:

“When the surveyor reviewed the census list on Day One, she asked us if there was a patient who was considered a suicide risk. We selected a patient who was on a one-to-one observation status. The surveyor reviewed the record for about an hour and read all of the assessments, the treatment plan, and the progress notes. Then she met with the nurse, the therapist, and the psychiatrist to review the case.

She was very interested in the initial suicide risk assessment. We had recently adopted a structured tool (instead of the few questions we had previously used) and she was impressed by that. She was also impressed that we were assessing protective factors as well as risk factors and said that many organizations overlook that.

She asked a lot of questions about how the clinical staff had been trained to use the suicide risk assessment tool and how we were assessing their competency. Frankly, this was a weak area for us. We had done a training for staff but had not developed a way to review their suicide risk assessments to make sure they were thorough and complete. We now include that as part of our qualitative clinical chart audits. While discussing competency, the surveyor also wanted to know how the mental health workers who were doing the one-to-one observations had been trained on that task and she asked one of them that question. The staff person was able to describe how she had been oriented by the nurse manager but we did not have any documentation of that task being included in her orientation. (We do now!)

The other place where she focused was on the connection between the suicide risk assessment and the treatment plan. She wanted to see if suicide risk had been included on the treatment plan as a problem. To our surprise, it wasn’t. Even though we had this patient on a one-to-one observation from the time of admission, we had not included suicide risk as one of the problems on the treatment plan.

Another topic she discussed with the team was how often the patient’s suicide risk was reassessed. This was a strength for us because we had recently implemented a structured, 10-item risk assessment that is done every shift by nursing for patients who are a suicide risk. The surveyor really liked that.

The final area of focus during this tracer was on the discharge planning process. The surveyor asked to see the discharge instructions that we give to patients. So, we had to pull a closed record for that. She was pleased to see that there were specific discharge instructions that included the patient’s medications and his follow-up appointments. There was also a Safety Plan that had been completed by the patient with his therapist prior to discharge. It listed the phone numbers of people who are part of his support system as well as the coping skills he had learned and could use in a crisis. There was also a number for the local Crisis Hotline. She was so impressed with this that she asked us for a copy!

Looking back, this tracer was a grueling one (2.5 hours including an interview with the patient) but we learned a lot from it. It helped us sharpen our treatment planning process related to suicide risk. It also prompted us to pay more attention to how we train and assess competency for staff working with potentially suicidal patients. Those are things that will definitely make us a better hospital!”