The countdown is on. July 1st is when the new Joint Commission requirements for suicide risk reduction go into effect. The revised National Patient Safety Goal NPSG.15.01.01 has seven new and revised elements of performance.
We do a lot of education on the new requirements and have also covered them in recent posts. (See the Q&A in our posts on 4/20/19 and 12/12/18)
Suicide Risk Reduction Efforts
Many of our clients are now using an evidence based tool for suicide risk screening and assessment. However, some are still using a “home grown” set of suicide risk questions which will not meet the new requirements.
We also see that some organizations don’t fully grasp all the additional requirements effective July 1. For that reason, we’re reviewing each of the seven new requirements and highlighting some of the common compliance issues we see.
Summary of New Requirements for Suicide Risk Reduction (NPSG.15.01.01)
The following are the seven elements of performance (EPs) for revised NPSG.15.01.01:
EP # 1: Assess and minimize environmental risks.
This EP actually has two requirements. The first is to conduct an environmental risk assessment to identify features that could be used to attempt suicide. The second requirement is to take actions to minimize these risks.
These requirements have been around for awhile and were previously scored under the Environment of Care standards. We see two issues with environmental risk assessments.
Often, they’re simply not thorough enough. The surveyor finds environmental risks that the organization hasn’t identified. Or, the risk assessment hasn’t been updated to show progress on mitigating the identified risks.
So, be sure to make your environmental risk assessment a living document. Keep it updated and report progress regularly in your Envronment of Care Committee.
EP # 2: Screen for suicidal ideation using a validated screening tool.
The most significant change here is that you must use a validated screening tool. A couple of questions about suicidal ideation and suicidal intent won’t meet the requirement. Examples of validated screening tools include the Columbia-Suicide Severity Rating Scale (C-SSRS), the PHQ-2 , the Patient Safety Screener, the TASR Adolescent Screener, and the ASQ Suicide Risk Screening Tool.
EP # 3: Conduct a suicide risk assessment using an evidence based process.
For patients who screen positive for suicidal ideation, you must conduct a suicide risk assessment. And you must use an evidence based process.
On 5/29/19, TJC published an FAQ on just what is meant by an “evidence based process.” Essentially, it means using an evidence based assessment tool in conjunction with clinical evaluation. Also, the assessment must directly ask about suicidal ideation, plan, intent, suicidal or self-harm behaviors, risk factors, and protective factors.
EP # 4: Document the patient’s overall level of suicide risk and the plan to mitigate the suicide risk.
This EP contains two requirements. The first is that the suicide risk assessment must determine and document a level of suicide risk such as high, medium, or low. The second requirement is there must be a plan to mitigate the suicide risk. The plan could include a heightened level of observation, suicide precautions, and any other interventions to reduce the risk.
EP # 5: Follow written policies and procedures for care of patients identified as a suicide risk.
The key point here is you must have a written policy on suicide risk assessment and care of the patient who is a suicide risk. At a minimum, the policy must address
- Staff training and competence
- Guidelines for reassessment
- Monitoring patient at high risk for suicide
What we often see is the organization has a suicide risk assessment process but not a written policy. This will not suffice. You must define your process in a written policy.
EP # 6: Follow written policies/procedures for counseling and follow-up care at discharge for patients identified as at risk for suicide.
Again, this is a new requirement for a written policy. The policy must address discharge planning for patients at risk for suicide. Many organizations don’t have a written policy on this. So, be sure to develop a policy, train staff, and document your discharge planning in the clinical record.
EP # 7: Monitor the effectiveness of your suicide risk assessment process. Take action as needed to improve compliance.
The goal here is to promote high reliability in your suicide prevention process. This can only be achieved if you strictly adhere to your policies and procedures.
So, you need to collect data on just how well your policies and procedures are being implemented. This data should become part of your ongoing Performance Improvement program.
Many root cause analyses (RCAs) done following suicides show the root cause was failure to adhere to an existing policy such as one to one observation for a high risk patient.
Suicide Prevention Resources
Looking for resources on how to implement these new requirements? Check out the TJC Suicide Prevention Portal on the TJC website. It has a host of resources and tools for implementing the new NPSG requirements. Between using these tools and closely following TJC’s new requirements, you’ll undoubtedly improve patient safety in your organization!