Accreditation

Q&A: Joint Commission talks ligature risk

Briefings on Accreditation and Quality, November 1, 2018

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 The Joint Commission’s 2019 Executive Briefings were held September 14 in New York City. Of the many topics discussed, suicide prevention and ligature risk was one of the most popular. Many attendees had questions on risk assessments, physical environment updates, and suicide screening of patients. 

In a live question-and-answer session, Kathryn Petrovic, MSN, RN-BC, The Joint Commission’s (TJC) field director of surveyor management and development, and Emily Wells, CSW, MSW, TJC’s project director of surveyor management and development, offered answers to some of those questions. This Q&A has been lightly edited for clarity.

Q: How realistic is it to have to screen everyone for suicide just coming in for a routine type of surgery or treatment?

Petrovic: That’s an excellent question, and we do not mandate universal screening, nor will our revisions to [National Patient Safety Goal] NPSG 15. It’s with a primary diagnosis of a behavioral health condition. 

Q: Should you write in your suicide prevention policy which tools you’re using for suicide screening? For example, if we use the Columbia tools, should we say “Columbia tools” on our policy?

Petrovic: You should. Staff need to be clear on where they’re supposed to document and what they’re supposed to document on in order to synthesize that risk.

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