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TJC accepting comment on proposed revisions for suicide risk through May 7

Hospital Safety Insider, March 29, 2018

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With CMS and accreditation organizations such as The Joint Commission (TJC) putting an emphasis on ligature risks of late, and TJC in particular regularly tweaking its standards aimed at reducing the risk of patient self-harm, it has been difficult for hospitals and other facilities to get a handle on these seemingly constant changes.

But now, after receiving feedback from both experts and customers and conducting some research, TJC is accepting comment on its expectations about suicide risk as the accreditor considers revisions to National Patient Safety Goal (NPSG) 15.

You will have a chance to weigh in on NPSG 15 through May 7. You can comment on the proposed revisions online or by mail. To read the full set of revisions, and for links and instructions on how to comment, go to the Field Reviews page.

TJC published the revisions on its Standards Field Reviews webpage earlier this week. The revisions, which will require hospitals to be more proactive in removing suicide risks from the physical environment, include proposed changes to both the general Hospital and the Behavioral Health Care accreditations programs.

Under the Hospital Accreditation program, a revised Element of Performance (EP) 1 will apply only to hospitals. The rest of the seven EPs — now up from just three — will apply only to patients in psychiatric hospitals or patients being treated for behavioral health problems in general hospitals, according to the field review information. The other EPs outline expectations of conducting suicide assessment of patients, documenting their risk and the plan to deal with their suicidal ideation, the need for written policies and procedures, and quality monitoring of the programs, among other things.

While TJC considers more revisions, don't wait around when you can prepare for survey. Thorough risk assessments and clear plans to mitigate danger to patients will be critical to satisfying concerns about ligature risk, said safety experts who spoke with HCPro for a recent story in our monthly Medical Environment Update newsletter.

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