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CMS will incorporate ligature risk recommendations

Healthcare Life Safety Compliance, November 1, 2018

This is an excerpt from a member only article. To read the article in its entirety, please login or subscribe to Healthcare Life Safety Compliance.

 After a long period of anticipation, it looks as though CMS will incorporate ligature risk recommendations from The Joint Commission (TJC) into comprehensive interpretive guidance it is creating to help reduce suicide and self-harm in healthcare facilities.

For some time, it looked as if CMS would issue its own guidelines, but in a July 20 memo to state survey directors, the agency indicated that it was satisfied that TJC’s directives were thorough enough to adopt themselves.

“The successful efforts by the TJC Suicide Panel to clarify and refine the issues involving ligature and safety risks are being incorporated into the revisions of the Interpretive Guidance,” wrote CMS Director of Quality, Safety & Oversight Group David R. Wright. “CMS felt that to repeat the work of TJC Suicide Panel (in which CMS participated) would not provide any substantive additional gains and would not be a productive use of the time and expertise of the participants.”

The issue goes back to February 2016, when TJC, acknowledging that suicide is the 10th leading cause of death, and claims more lives than traffic accidents and more than twice as many as homicides, issued Sentinel Alert #56: Detecting and Treating Suicide Ideation in All Settings as a way of bringing attention to the problem. 

Effective March 1, 2016, TJC ordered its surveyors to immediately start placing more emphasis on the prevention of suicides in hospitals and start paying close attention to the assessment of potential ligature (hanging) injuries, suicide, and self-harm monitoring, especially in psychiatric hospitals and inpatient psychiatric patient areas in general hospitals.

This is an excerpt from a member only article. To read the article in its entirety, please login or subscribe to Healthcare Life Safety Compliance.

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