Joint Commission Revises Suicide Prevention National Patient Safety Goal

Accreditation Insider, December 11, 2018

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The Joint Commission (TJC) this week announced revisions to its suicide prevention National Patient Safety Goal (NPSG) to improve quality and safety of care for patients treated for behavioral health conditions and who are identified as high-risk for suicide.

Effective July 1, 2019, NPSG.15.01.01 (Reduce the risk for suicide) is applicable to all Joint Commission-accredited hospitals and behavioral healthcare organizations. The revised requirements are based on more than a year of research, public field review, and analysis with multiple panels convened by TJC and representing provider organizations, suicide prevention experts, behavioral facility design experts, and other key stakeholders.

The requirements are detailed in a new R3 Report published by TJC. The NPSG encompasses seven elements of performance (EP) that TJC will use to review hospitals and behavioral healthcare organizations during accreditation surveys. This is an increase over the three EPs in the current version of NPSG.15.01.01 (Identify individuals at risk for suicide).

“The science of suicide prevention has really advanced over the past few years, including better tools for screening, assessment of suicidal ideation, identification of environmental hazards in health care facilities, and methods to prevent suicide after discharge,” said David W. Baker, MD, MPH, FACP, executive vice president, TJC’s Division of Health Care Quality Evaluation, in a release. “We had not updated the NPSG since its original release in 2007. This revised version and the accompanying resource compendium will more robustly support health care organizations in preventing suicide among patients in their care.”

The new and revised requirements cover:

  • Environmental risk assessment and action to minimize suicide risk
  • Use of a validated screening tool to assess at-risk patients
  • Evidence-based process for conducting suicide risk assessments of patients screened positive for suicidal ideation
  • Documentation of patients’ risk and the plan to mitigate
  • Written policies and procedures addressing care of at-risk patients and evidence staff are following them
  • Policies and procedures for counseling and follow-up care for at-risk patients at discharge
  • Monitoring of implementation and effectiveness, with action taken as needed to improve compliance

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