This member-only article appears in the March issue of Patient Safety Monitor Journal.
The Joint Commission (TJC) announced revisions to its suicide prevention National Patient Safety Goal (NPSG) November 27. NPSG 15.01.01 now has seven elements of performance (EP), up from three. All the changes are listed in R3 Report 18 and will take effect July 1, 2019. The update applies to all TJC-accredited hospitals and behavioral healthcare organizations.
The report says the new EPs aim to improve quality and safety of care for patients treated for behavioral health conditions and who are identified as high-risk for suicide. TJC officials say the revised requirements are based on more than a year of research, review, and analysis with multiple panels convened by TJC and representing provider organizations, suicide prevention experts, behavioral facility design experts, and other key stakeholders.
“The science of suicide prevention has really advanced over the past few years, including better tools for screening, assessment of suicidal ideation, identification of environmental hazards in health care facilities, and methods to prevent suicide after discharge,” said David W. Baker, MD, MPH, FACP, executive vice president of TJC’s Division of Health Care Quality Evaluation, in a release. “We had not updated the NPSG since its original release in 2007. This revised version and the accompanying resource compendium will more robustly support health care organizations in preventing suicide among patients in their care.”
EPs 2–7 only apply to psychiatric hospital patients or general hospital patients for whom the main reason for treatment is a behavioral health problem.
EP 1: Environmental risk assessment and action to minimize suicide risk
Summary: There are many common objects and features in hospitals that patients could potentially use to self-harm. An environmental risk assessment helps identify those items and whether they can be safely removed. Which areas of your building need this assessment done depends on what type of facility you have (behavioral healthcare facility vs. hospital).
Notes: Once your assessment is done, you can use your findings to make a ligature checklist. This will help staff remove dangerous items from a room when a new patient comes in.
EP 2: Use of a validated screening tool to assess at-risk patients
Summary: It’s common for patients with behavioral health conditions to have depressive or suicidal thoughts, and screening can help bring a person’s risk to light. Anytime someone comes in for a behavioral health problem, use a validated tool to screen the person for suicide ideation. Examples of suitable tools include:
Columbia-Suicide Severity Rating Scale
PSS-3 Screener (for ERs)
Whatever tool you use ought to be written into your hospital’s policy.
Notes: General hospitals only have to screen patients when the main reason for their visit is a behavioral health condition. For example, if a patient came in because of injuries from a car crash, you wouldn’t need to perform a screening for suicidal ideation—however, if you suspect a person’s injuries are from self-harm (i.e., the person drove the car into the tree on purpose), the patient should be screened.
Also note that while universal suicide screening for every patient isn’t a TJC requirement, some hospitals have successfully implemented it at their facility.
EP 3: Evidence-based process for conducting suicide risk assessments of patients screened positive for suicidal ideation
Summary: Every person thinks differently, so when a patient screens positive for suicide ideation, you need to follow up to determine the severity of the condition. Has the person decided to act on these thoughts? Does he or she have a plan for how to commit suicide? Does the person have a history of self-harming behavior, and has he or she engaged in that behavior recently? What are the person’s risk factors, triggers, and safeguards? Providers need to know these things if they’re to properly treat patients.
Notes: The R3 report says “EPs 2 and 3 can be satisfied through the use of a single process or instrument that simultaneously screens patients for suicidal ideation and assesses the severity of suicidal ideation.” It names the Columbia-Suicide Severity Rating Scale as a tool that meets the requirement for EPs 2 and 3.