National Patient Safety Goal (NPSG) Standard NPSG.15.01.01 Suicide Prevention

Effective July 1, 2020, National Patient Safety Goal (NPSG) Standard NPSG.15.01.01 Suicide Prevention will apply to Joint Commission–accredited critical access hospitals.

Most Critical Access Hospitals have been striving toward achieving this Patient Safety goal for some time now. We want to share this with everyone as Suicide Prevention and Ligature Risk is an extremely high focus area and if identified on survey – may lead to a Preliminary Denial of Accreditation.

NPSG.15.01.01 summary of the standard:
Psychiatric distinct part units in critical access hospitals should conduct environmental risk assessments to be ligature resistant.

General units in critical access hospitals are not expected to be ligature resistant; however, the organization should assess the patient room, where patients at high risk for suicide may reside, to determine the items that routinely could be removed.

Individuals being treated or evaluated for behavioral health conditions as their primary reason for care need to be screened for suicide using a validated tool. The NPSG does not require universal screening.

The critical access hospital develops a plan to mitigate suicide based on an individual’s overall level of risk.

The critical access hospital follows written policies and procedures for counseling and follow-up care for individuals identified as at risk for suicide.

In short, ensure that the following have been achieved no later than June 2020:
1) An environmental risk assessment for ligature points anywhere a suicide patient may be cared for;
2) A validated tool for screening has been adopted and staff have been trained;
3) Policy and processes have been developed for making a room safer by removing hazard items when a at risk patient is placed in the space and
4) Policy and processes are in place for continuous observation for identified patients at risk of self-harm or suicide.

The following links may be helpful in developing and implementing these processes:

Suicide Risk Factors and Risk Assessment Tools: A Systematic Review
Patient Safety Assessment Tool (PSAT)
Joint Commission Suicide Prevention Portal

Remember – risk assessments are a continual process and must be kept up to date. Ensure that ALL staff are trained in using the screening tools and how to implement the developed policy or processes associated to preventing suicide within a healthcare setting.

For more details, contact us at:

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