Mitigating suicide risk in behavioral health settings

Accreditation Monthly, November 14, 2007

Is the physical environment within your behavioral health settings (including the emergency department) built and equipped in a manner that minimizes the risk of a patient causing harm to self or committing suicide? 

Warning: Accreditation clients of The Greeley Company report that Joint Commission (formerly JCAHO) surveyors seem very interested in testing this question during full unannounced surveys. Evidence suggests a requirement for improvement is being written often at EC.8.10, Element of Performance 4, a "C" EP with a Measure of Success. 

EC.8.10 EP 4 requires that "areas used by the patient are safe, clean, functional, and comfortable." You might wonder how the surveyor segues from this seemingly innocuous EP language to scoring an RFI at EC.8.10 merely because he or she finds that your behavioral health unit has suspended lay-in grid ceilings or exposed plumbing pipes under the sinks in patient bathrooms. 

Very simply, the surveyor is connecting the dots between EC.8.10 and EC.1.10 EP 4, which requires "[completion of a] comprehensive, proactive risk assessment that evaluates the potential adverse impact of buildings, grounds, equipment . . . on the safety and health of patients . . . coming to the hospital's facilities."  If during a survey you are unable to produce a well-reasoned proactive risk assessment that is followed by actions to mitigate the risk of injury to self in the behavioral setting, you have placed your organization at the surveyor's mercy; he or shemay cite whatever happens to strike him or her as posing a potential risk to your patients.

I advise all of our clients to base the behavioral health unit proactive risk assessment to mitigate suicide or injury on the seminal document titled, Design Guide for the Built Environment of Behavioral Health Facilities, Second Edition, written by David M. Sine and James M. Hunt and distributed through the National Association of Psychiatric Health Systems. You can link to the document at documents/REV9editedFINAL_001.pdf.

Although the authors understandably apply caveats and qualifications to the scope of this guide, you should consider it for all intents and purposes a definitive listing of best practices to creating as safe an environment for your behavioral health patient as is currently possible. Comparing your environment and equipment against that recommended in this guide will form a gap analysis identifying issues in which your environment falls short of these best practice norms. An action plan and budget can then be created to address these shortcomings. You can certainly decide to deviate from these norms and choose not to take action with a particular issue or two surfacing in the gap analysis, but you had better be prepared to offer a reasoned explanation of why you think your alternative is as safe as that recommended in the guide.

Last month, I addressed the rise in Joint Commission findings pertaining to the annual evaluation of the organization's infection control (IC) plan and risk assessment. I want to provide an additional warning to look out for IC.1.10, EP 3, which requires all applicable organizational components or functions to be integrated into the hospitalwide plan. A favorite finding of surveyors recently has been to note that the infection control plan, risk assessment, surveillance activities, and influx plan for the organization's home health agency or skilled nursing facility, etc., is not integrated and rolled up into the overall organizational IC master plan or risk assessment.

Speaking on behalf of my colleagues at The Greeley Company, any one of us would be happy to assist you in bullet-proofing your organization against receiving an RFI for missing the behavioral health unit built environment proactive risk assessment or one or more of the infection control standards. We specialize in helping to craft policies and effective processes designed specifically to fit your organization. It may also be time to schedule an Unannounced Survey Vulnerability Visit by one of our Greeley mock survey teams. For more information, please call Stacey Koch, Director of Client Relations, at 888/749-3054, ext. 3193.

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