Accreditation

HFAP revises ligature risks standards

Briefings on Accreditation and Quality, September 1, 2018

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Editor's note: HFAP announced these standards won't be revised again due to the July CMS memo on ligature risks.  

To keep themselves as closely aligned with CMS as possible, HFAP has updated their Acute Care Manual with new prepublication requirements on removing ligature (hanging) risks in rooms meant for suicidal patients. Several standards have been affected: 

04.01.01 – Staff Training – Identification of Patients at Risk for Harm

11.01.01 – Periodic Monitoring for Safety Issues

11.01.02 – Building Safety

11.01.08 – Review of Safety Policies and Procedures

11.02.01 – Building Security

13.00.01 – Life Safety Code Compliance

13.01.06 – Exit Discharge

13.05.09 – Utility Systems

15.01.17 – Privacy and Safety: Safe Setting

15.01.19 – Privacy and Safety: Identify Patients at Risk

15.01.20 – Privacy and Safety: Environmental Risk Assessment

27.03.01 – Privacy and Safety: Identify Patients at Risk

27.03.02 – Privacy and Safety: Environmental Risk Assessment

Alise Howlett, AIA, CFPE, CHFM, is HFAP’s emergency management, physical environment, and life safety standards advisor. And Karen Y. Beem, MS, RN, serves on HFAP’s standards interpretation staff and participates in the development and revision of standards.

This Q&A has been lightly edited for clarity.

Q: In your opinion, what are the most significant changes to these standards? How will they help patients? 

Beem: The most significant change is the requirement for proactive assessment of risk and subsequent action. A hospital should be considered a safe place, and while we’ve had a level of awareness of folks who are violent or potential dangers to others, attention to self-harm has been a more recent area of focus. 

The need to take action to address risk isn’t limited to the psychiatric unit. There are patients throughout a hospital who have arrived with behavioral health issues and others who, due to a medical condition or the drugs they’re receiving, have an altered mental status. 

 

This is an excerpt from a member only article. To read the article in its entirety, please login or subscribe to Briefings on Accreditation and Quality.

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