Accreditation

Suicide goal applicability unclear for hospitals

Briefings on The Joint Commission, September 1, 2006

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1. -list the implementation expectations (IE) for the JCAHO's 2007 National Patient Safety Goal (NPSG) for suicide risk assessment

The language of the JCAHO's new 2007 NPSG addressing patient suicide has caused confusion in the field about its applicability in hospitals that lack designated psych services.

Goal #15, "The organization identifies safety risks inherent in its patient population," has been added to the NPSG lists for the hospital, critical-access hospital, home care, and behavioral healthcare accreditation programs and must be implemented by January 1, 2007.

But the goal's single requirement is causing confusion, partly because of the way it's written, and partly because of varied responses provided from the JCAHO's standards interpretation group (SIG) to hospitals seeking clarification. The hospital and critical-access hospital requirement, 15a, reads, "The organization identifies patients at risk for suicide."

There is additional language following the requirement: "Applicable to behavioral healthcare, psychiatric hospitals, and general hospitals treating patients for emotional or behavioral disorders."

Clarity is sought, but not necessarily found, in the requirement's IEs. Following is the text of the IEs, along with analysis by the accreditation consultants of The Greeley Company, a division of HCPro, Inc., in Marblehead, MA:

1. "The risk assessment includes identification of specific factors and features that may increase or decrease risk for suicide." Analysis: Most units already have such elements of assessment in place. This should not be anything new.

2. "The [patient]'s immediate safety needs and most appropriate setting for treatment are addressed." Analysis: This requirement is poorly worded. Surveyors and the SIG could draw different (and widely varying) interpretations.

3. "The organization provides information such as a crisis hotline to individuals and their family members for crisis situations." Analysis: This requirement is poorly worded. We have been told that JCAHO means that, upon discharge, patients who were assessed to be at risk for suicide are given recourse for crisis intervention. We have been informed that hospitals do not have to provide a crisis hotline directly, but may simply direct the patient and family to community resources.

Many in the field say they first turned to the JCAHO's Web site for answers about the goal's applicability. In February, the JCAHO posted a five-page frequently asked questions (FAQ) document to address questions about the applicability of the 2006 NPSGs. However, no FAQs yet exist for the 2007 NPSGs. It is expected that the JCAHO will update the document for the 2007 NPSGs, but it is not known when. The 2006 FAQ document was updated in February-more than a month after implementation was required.

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