Evaluating suicidal risk is a critical aspect of care in healthcare organizations. The use of a validated screening tool is the second element of performance of The Joint Commission’s National Patient Safety Goal 15 to reduce suicide risk. During our visits to organizations, we observed two key areas for consideration with compliance and effectiveness of this important requirement.
Compliance.
A tool is validated when the instrument is determined to measure what it was created to measure and should not be altered as changes to the tool can negate its validity. With suicide risk screening tools, alterations including omitting questions lead to an inaccurate tool and hence invalid outcome. Additionally, changing the order of the questions can negatively affect how questions are answered which can also potentially affect the tool’s predicted outcome. During visits to organizations, we have observed both modifications to tools and the use of older versions. We recommend checking the direct source of your validated tool for the latest version and the accurate duplication of the tool as designed. If any modifications are being considered, it is important to contact the tool creator to discuss the changes before making any modifications.
Effectiveness.
Through its quality program, organizations may decide to change which suicide risk screening tool will be used. This decision could be influenced by several factors such as the number of false positives or negatives, ease of use, and clinician feedback. Organizations such as The Joint Commission have identified validated and evidence-based tools for consideration. We encourage proactive methods like Failure Mode and Effects Analysis (FMEA) to outline the screening and assessment steps to identify potential issues during the implementation process. With a data-driven and proactive approach, organizations can instill a compliant and effective screening process.
In closing, when was the last time your organization’s validated tools were checked for accuracy and the latest version?
Please contact us for questions or more information at 704-573-4535 or info@courtemanche-assocs.com.
Resources
The Joint Commission (2023). Suicide Prevention - Resources. https://www.jointcommission.org/resources/patient-safety-topics/suicide-prevention/
The Joint Commission (2022). Suicide Risk Screening in Healthcare Organizations. https://www.jointcommission.org/resources/news-and-multimedia/blogs/dateline-tjc/2022/03/suicide-risk-screening-in-healthcare-organizations/
Courtemanche & Associates specializes in Healthcare Accreditation and Regulatory Compliance Consulting Services. With over 29 years of being in business and 100+ years of healthcare experience amongst our consulting team, we are ready to assist with your accreditation and regulatory compliance needs.