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Changes to NPSG 15 – Suicide Prevention

By May 14, 2019On the Radar

Effective July 2019 – New Elements of Performance from the Joint Commission.  These new requirements are designed to improve the quality and safety of care for those who are being treated for behavioral health conditions and those who are identified as high risk for suicide.

Because there has been little to no improvement in suicide rates in the U.S., and since suicide is the 10th leading cause of death in the country, The Joint Commission re-evaluated the NPSG in light of current practices relative to suicide prevention.  (Joint Commission R3 Report, Issue 18, updated May 6, 2019)

NPSG 15.01.01 include:

EP 1:  For psychiatric hospitals and psychiatric units in general hospitals: The hospital conducts an environmental risk assessment that identifies features in the physical environment that could be used to attempt suicide; the hospital takes necessary action to minimize the risk(s) (for example, removal of anchor points, door hinges, and hooks that can be used for hanging).

For nonpsychiatric units in general hospitals: The organization implements procedures to mitigate the risk of suicide for patients at high risk for suicide, such as one-to-one monitoring, removing objects that pose a risk for self-harm if they can be removed without adversely affecting the patient’s medical care, assessing objects brought into a room by visitors, and using safe transportation procedures when moving patients to other parts of the hospital.

Note: Nonpsychiatric units in general hospitals do not need to be ligature resistant. Nevertheless, these facilities should routinely assess clinical areas to identify objects that could be used for self-harm and remove those objects, when possible, from the area around a patient who has been identified as high risk for suicide. This information can be used for training staff who monitor high-risk patients (for example, developing checklists to help staff remember which equipment should be removed when possible).

EP2:  Screen all patients for suicidal ideation who are being evaluated or treated for behavioral health conditions as their primary reason for care using a validated screening tool.

EP3:  Use an evidence-based process to conduct a suicide assessment of patients who have screened positive for suicidal ideation. The assessment directly asks about suicidal ideation, plan, intent, suicidal or self-harm behaviors, risk factors, and protective factors.

Note: 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.

EP4:  Document patients’ overall level of risk for suicide and the plan to mitigate the risk for suicide.

EP5:  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

EP6:  Follow written policies and procedures for counseling and follow-up care at discharge for patients identified as at risk for suicide.

EP7:  Monitor implementation and effectiveness of policies and procedures for screening, assessment, and management of patients at risk for suicide and take action as needed to improve compliance.

Conclusion:  Organizations should also note the CMS DRAFT-QSO-19-12-Hospitals – Clarification of Ligature Risk Interpretive Guidelines released on April 19, 2019 which provides guidance and clarification for expectations related to ligature risk and suicide prevention. CMS has proposed the following at §482.13(c)(2) – The patient has the right to receive care in a safe setting.  Interpretive Guidance includes: Safety measures that ensure these patients identified as being at risk are protected in a non-psychiatric and unlocked setting may include:

  • 1:1 monitoring with continuous visual observation or video monitoring, if appropriate (not recognized/recommended by Joint Commission);
  • Removal of sharp objects;
  • Removal of equipment that can be used as a weapon or to inflict harm;
  • Securing personal belongings; and
  • Removal of any other item(s) that may contribute to harmful behavior.

If organizations have yet to perform the required environmental risk assessments and review of related policies for these topics, the risk of Immediate Threat to Health and Safety (Immediate Jeopardy) increases ten-fold with each passing day.  Care in a safe setting is the expectation and there is no forgiveness from accrediting / regulating agencies with these patient care processes.

James Ballard

Author James Ballard

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